tag:blogger.com,1999:blog-8066238290370557389Wed, 21 Feb 2018 05:31:54 +0000MRSAhand hygieneH1N1CDCswine fluinfluenzacontact precautionsinfluenza vaccinationantibiotic resistanceCLABSISHEAhealthcare associated infectionsC. difficileantimicrobial stewardshipactive surveillancepublic reporting of HAIsconflict of interestebolainfection controlwhite coatsmandatory vaccinationpandemicEbola virusinfection preventioninfluenza vaccinebare below the elbowStaphylococcus aureusclothingoutbreakhealthcare workersGetting to zeroIDSANHSNVREfecal transplantqualitysurgical site infectionCAUTIClostridium difficileICHEKPChealthcare reformjamaAPICFDAMDROMycobacterium chimaerachlorhexidinefood safetypresenteeismCMSVAPWHOguest bloggerssivaccinesN95 maskRichard Wenzelanimal productionanti-vaccine movementantibioticeconomicsHIVPublic reportingheater cooler unitspatient safetysurveillancetuberculosisIDWeekNDM-1environmental contaminationepidemiologyoutbreaksstewardshipadverse consequencesannual match day messnew york timesPPEacinetobacterpublic healthEbola hemorrhagic feverHAIMaryn McKennaNIHUKhospital quality indicatorsinfectious diseasesmasksopen accesspay for performanceCREagribusinessantimicrobial resistanceeccmidNEJMdiekemafundingiowalegislative mandatesmediawhite coatAtul GawandeBUGGCDIPharmablogchecklistchgconfirmation biasdrug discoveryglovesmeaslesnecktiesreligionsuperbugtransplantationIOMMSSAMike EdmondTamifluVA healthcareVeterans Affairsahrqantibacterial resistanceantimicrobialscarbapenemasecompliancedecolonizationiatrogenic meningitismicrobiomemupirocinprofessionalismquasi-experimentalrandomized trialsepsistransmissionventilator associated pneumoniaCIDESBLICD-9 codesLegionellaNTMSHEA2015The Joint Commissioncognitive biascompensationguidelineshorizontalmultidrug resistant gram negativesnoroviruspediatricresearch prioritiessepkowitzsurveyAJICARICCepheidEnglandICAACPrevention and Public Health FundTEDabstractadministrative claims dataalcohol hand rubanthraxbiasclinical microbiologycluster-randomized trialcostdisinfectionepidemichandwashinghospital acquired infectionslab coatslong-term care facilitiesmeta-analysismicrobiologyorlandopandemic influenzaprophylaxisrabiesscreeninguniversal glovingvideowhole genome sequencing#VisualAbstractAMABMJBalamuthiaDidier PittetDon BerwickIgnaz SemmelweisLatent tuberculosisLatin AmericaLyme diseaseMMWRMichiganPCRPeter PronovostREDUCE MRSASCIPSHEA2016VRSAadverse eventsalcohol gelannalsblood culture contaminationbundlescarbapenemenvironmentescmidevidence-based medicinefungal meningitisgram negativesinfectious diseases consultationlancet IDmichael edmondnursing homesobituaryoseltamivirpennsylvaniapigsproduct designsocial networkssubspecialty matchsummer campvaccinevancomycinASM General MeetingBen GoldacreCMS ruleCanadaDallasDeus ex machinaHHSHICPACHarbarthICPICINHInfection Control DepartmentsLTCFNaturePPIsPositive outcome biasPrevention EpicentersSTAR*ICUairborne transmissionalgorithmaspergillosiscarbapenem-resistant 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SencerE coliEAADEIDEIPESCKAPEETSYEUEd YongEdwin KilbourneEisenhowerErik DubberkeEuropean Antibiotic Awareness DayEuropean UnionEvelina TacconelliEzra KleinF1000FacebookFake NewsFlintFlorence NightingaleFranceFrancis CollinsFreakonomicsFrederick Winslow TaylorFridayFundraiserGBSGBV-CGoossensGuillane-BarreGünter KampfHACHADSHBOHIVMAHMPHSCTHaitiHajjHal VarianHalloweenHancherHarkinHarrogateHarveyHealth AffairsHill CriteriaHillemanHines VAHootersHorwitzHurricaneHuttnerHändewaschenID ConsultsIHI Global Trigger ToolIPSIQITFARIan SmithIllinois APICIndianaIntermountainIowa CityIrmaIsa MoroIsraelJack LondonJames BagianJanet Lane-ClayponJennifer BrightJim Yong KimJohn SnowJohns HopkinsKPMGKaiserKantKathryn SchulzKrampusLA TimesLGBTLRTILabbitLabor DayLas VegasLawrence KasdanLeapfrogLiberiaLona ModyLord KelvinLoserMICMLBMS2MadisonMalawiMalcolm GladwellManuscript ProvenanceMarc BontenMary Dixon-WoodsMatt SamoreMayan CalendarMerckMeritMiamiMichael ClimoMichael GravesMichael JordanMichael RubinMike 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loopsfellows coursefellowshipfemoralfestivusfitness costflavinoidsfloorsflu near youfluoroquinolonesfocus groupfomitesfriedenfriendship paradoxfungifusariumgarbagegastrectomygentamicin spongesgift ideagleetgooglegovernment shutdowngownsgrand roundsgrant reviewgrantsgreynessguardiangun violencehVISAhabithands-freeheealthcare workershierarchyhigh fivehilary babcockhipho chi minh cityholidayhomicidehoranhospital acquired meningitishospital trashhuman factorshuman microbiome projecthumanismhumanityhumidtyhvachygienehypertensioniPatientiTouchicebergimplementationincentivesincidenceinfectioninfluenza mapinfluninjury preventionintelligenceinterventionsintoxicationinvisibleiowa public radioirelandirritable bowel syndromejet injectorjonathan risenjugularkefirkikuchikirklandkitchen sinkkneela ninalab safetylaboratory capacitylarsonlayoffsleadershipliteratureliving wagelower respiratory tract infectionlucy and rickylumbar puncturelunch breaklyingmagnetsmalariamandatemapsmarsmass panic run for the hillsmeanmecCmeddling kidsmedianmedical meetingsmedical wastemetabiasmetagenomicsmetronidazolemichael eisenmicrobiological Industrial Complexmindfulnessminnesotaminoritymobile phonesmodemodelsmolecular typingmonitoringmonoclonal antibodymorbiditymotilitymousemultidisciplinarymunoz-pricemurdermurinenasal carriagenational academynatural disasterneedle exchange programsneedle-lessneil youngneisseria meningitisnetwork meta-analysisnew york citynewborn nurserynightmare bacterianoisenoninferioritynonpaymentnontoxigenic C. difficilenorwalknovelnumeratornumiobservationontarioopioidoregonorphan drugsoutpatientoversellingoveruseoxapassive surveillancepasteurizationpatient zeropay wallpbspeer reviewpenguinspenicillinperianalpersonal reflectionpet visitationphysician-assisted suicidepigeon drive the buspigeonsplos medicinepneumocystispneumoniapneumothoraxpodcastpodiumpoisoningpoliopoliticspopulationporkportlandpositive predictive valuepost-acute carepost-apocalypsepost-operative antibioticsposterpostmodernismpotsdampower paradoxpractical wisdompre-operativepredatorypredatory publishingpredictionprediction marketsprediction rulesprimary amoebic meningoencephalitisprimary careprivate roomsprobioticsprocalcitoninprofitsprotestprotopathic biaspsychologyqSOFAquantitative culturesquestionquestionsrapid diagnosticsratesratsraw milkrecallregression to the meanrenalrepresentationresource-limited settingsretirementreturn on investmentrhinovirusrick mercerrifampinrifaximinrobberyrubinsafe hospitalssanitariumsanitationscabiesscandalscarlet feverschwagshameless self promotionsharps injuryshvsignificancesignssimulation gamesneezesosocial distancingsocial learningsoilspacespace travelsportssquirrelsst-398star warsstreptomycinsubclaviansubjective realitysummer readingsunshinismsupplysupply chainsurgerysurgical complicationswinesyphilistamiflu-resistantteixobactinthanksgivingthe nightly showtigecyclinetime-dependent variablestime-series analysistop 10tourismtransvaginal ultrasoundtriclocarbantuberculinturkeytwo monitorstyphoid maryunintendedunited statesurinary catheterurinevalidityvan SchaikvanMverticalveterinariansvietnamviewpointvirulencewacky stuffwaiting roomswall street journalward roundswashingtonwhiteboardwidmerworkwork-life balanceworld health dayworld mrsa daywristwatchesyear in infection controlyogurtyou can't fight fashionControversies in Hospital Infection PreventionPondering vexing issues in infection prevention and controlhttp://haicontroversies.blogspot.com/noreply@blogger.com (Dan Diekema)Blogger1782125tag:blogger.com,1999:blog-8066238290370557389.post-7008788511349960988Fri, 16 Feb 2018 20:31:00 +00002018-02-16T16:26:26.168-06:00contact precautionsglovesjamaMRSAuniversal gloves and gownsviewpointVREEven NFL Stars LOVE Contact Precautions <div class="separator" style="clear: both; text-align: center;"><a href="http://3.bp.blogspot.com/-gA_gKROB4QQ/Woc9w8CuCHI/AAAAAAAACiU/NZ8FBhKNp6gPU7HGN88ze8MoRZzv2QqQACK4BGAYYCw/s1600/Gronk.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="416" src="https://3.bp.blogspot.com/-gA_gKROB4QQ/Woc9w8CuCHI/AAAAAAAACiU/NZ8FBhKNp6gPU7HGN88ze8MoRZzv2QqQACK4BGAYYCw/s640/Gronk.png" width="640" /></a></div><br />What do we <a href="http://haicontroversies.blogspot.com/2015/09/lovin-contact-precautions-this-time-in.html">love</a> most of all on this blog? Yup - contact precautions. <a href="http://haicontroversies.blogspot.com/2015/11/and-another-reason-to-hate-contact.html">Humor</a>!<br /><div><br /></div><div>Well, I do have respect for the <a href="http://pediatrics.aappublications.org/content/131/5/e1515.long">utility of gloves</a> in preventing HAIs and MDRO transmission- but I've never been sure of gowns. It's just that they are pretty annoying to don and doff and little evidence supports any additional benefit above wearing just gloves. I mean, if Rob Gronkowski from the almost champion New England Patriots <a href="http://wpri.com/2018/02/14/gronkowski-family-visits-hasbro-childrens-hospital-makes-donation/">can't even put on a gown correctly</a>, what chance do we mere mortals have, seriously. Maybe that's the reason why the <a href="https://jamanetwork.com/journals/jama/fullarticle/1752753">benefits of gowns and gloves</a> for preventing MRSA and VRE are so hard to estimate?<br /><br />There are many other reasons why the benefits of contact precautions for endemic MDRO are so hard to quantify, of course. In this week's JAMA, Mike Rubin, Matt Samore and Anthony Harris have written a very nice <a href="https://jamanetwork.com/journals/jama/fullarticle/2672842?resultClick=1">Viewpoint</a> acknowledging the limitations in the current literature. &nbsp;In addition, they point out why studying infection prevention interventions is so tricky and suggest a path forward. They should be commended for their thoughtfulness and honesty - something those of us (including me) who support other policies with even weaker evidence bases should remember. If Gronk is having trouble with contact precautions, it's OK if some of the rest of us do too.</div>http://haicontroversies.blogspot.com/2018/02/even-nfl-stars-love-contact-precautions.htmlnoreply@blogger.com (Eli Perencevich)0tag:blogger.com,1999:blog-8066238290370557389.post-2681001133188624409Wed, 07 Feb 2018 23:03:00 +00002018-02-07T17:09:03.523-06:00antibacterial resistancegates foundationsurveillanceWHOGlobal antibiotic resistance surveillance a.k.a. GLASS: one step closer to saving the world <div class="MsoNormal"><a href="https://3.bp.blogspot.com/-7RMSvWTOxaQ/WnuFCWVP_iI/AAAAAAAAAgs/4UmpANBwUVkrfszT54JU8JYIW-9KW6-JACLcBGAs/s1600/save-world-19754205.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="1118" data-original-width="1300" height="275" src="https://3.bp.blogspot.com/-7RMSvWTOxaQ/WnuFCWVP_iI/AAAAAAAAAgs/4UmpANBwUVkrfszT54JU8JYIW-9KW6-JACLcBGAs/s320/save-world-19754205.jpg" width="320" /></a><span style="font-family: &quot;times&quot; , &quot;times new roman&quot; , serif;">New surveillance data released a week ago by the World Health Organization (WHO) illuminates a step towards a coordinated and standardized way to perceive the AR problem worldwide. Most of the report focuses on healthcare-related bacteria, but it is not limited to this. Probably a hidden gem includes a standardized characterization of each countries capacity and reporting infrastructure. <o:p></o:p></span></div><div class="MsoNormal"><span style="font-family: &quot;times&quot; , &quot;times new roman&quot; , serif;"><br /></span></div><div class="MsoNormal"><span style="font-family: &quot;times&quot; , &quot;times new roman&quot; , serif;">In the first report from the WHO's Global Antimicrobial Resistance Surveillance System (GLASS), 22 countries submitted data on 507,746 isolates with antibiotic susceptibility testing results (range 72-167,331 per country). To no surprise, <i>Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus, Streptococcus pneumoniae,</i>&nbsp;and&nbsp;<i>Salmonella</i>&nbsp;spp are the most commonly reported resistant bacteria; most of these reports do come from sentinel laboratories reported to their country designee. Although some countries report high values of “percent resistance”, often these reflect a single laboratory. <o:p></o:p></span></div><div class="MsoNormal"><span style="font-family: &quot;times&quot; , &quot;times new roman&quot; , serif;"><br /></span></div><div class="MsoNormal"><span style="font-family: &quot;times&quot; , &quot;times new roman&quot; , serif;">The direction GLASS is going is forward!&nbsp;</span><span style="font-family: &quot;times&quot; , &quot;times new roman&quot; , serif;">Which is great. Its strength right now is to provide a one stop shop and platform to quickly read how a country representative describes their AR surveillance effort.</span></div><div class="MsoNormal"><span style="font-family: &quot;times&quot; , &quot;times new roman&quot; , serif;">You can choose a country and view data here:<a href="http://apps.who.int/gho/tableau-public/tpc-frame.jsp?id=2004" target="_blank">Tableau feature of GLASS</a> <o:p></o:p></span></div><div class="MsoNormal"><span style="font-family: &quot;times&quot; , &quot;times new roman&quot; , serif;"><br /></span></div><div class="MsoNormal"><span style="font-family: &quot;times&quot; , &quot;times new roman&quot; , serif;">This may be helpful for grant writing, collaborations, and consultations; however, for a variety of reasons, the actual results are a bit data-penic, and somewhat of a convenience sample. This is not to fault the GLASS effort at all - countries clearly with the capacity to have insight, visualization, and concrete values on the magnitude of their resistance problem didn’t submit data to this data call.&nbsp; Although the reasons may vary and all be very valid, it does make the report less of a comprehensive source of global variations in the magnitude of the problem. The power of standardize reporting of “representative” laboratories can (and I believe will) help local health and government leaders prioritize efforts in country. Hopefully additional countries (including the U.S.) will contribute to future data calls. Full report is here:<a href="http://apps.who.int/iris/bitstream/10665/259744/1/9789241513449-eng.pdf?ua=1" target="_blank">GLASS 2017</a> <o:p></o:p></span></div><div class="MsoNormal"><span style="font-family: &quot;times&quot; , &quot;times new roman&quot; , serif;"><br /></span></div><div class="MsoNormal"><span style="font-family: &quot;times&quot; , &quot;times new roman&quot; , serif;">Regardless, WHO now provides all of us with an interactive feature (Tableau) to view country specific infrastructures (I counted 37 countries) and data (from 22 countries, although I have not checked all 22). <o:p></o:p></span></div><div class="MsoNormal"><span style="font-family: &quot;times&quot; , &quot;times new roman&quot; , serif;"><br /></span></div><div class="MsoNormal"><span style="font-family: &quot;times&quot; , &quot;times new roman&quot; , serif;">I don’t envy WHO staff trying to herd cats (cats as in those of us having [or having had] a say in AR surveillance reporting) to try to get all countries to report out data to them in a standard way, but I do applaud their efforts and hope the data submissions become more comprehensive – and thus the interface more usable. <o:p></o:p></span></div><span style="line-height: 107%;"><span style="font-family: &quot;times&quot; , &quot;times new roman&quot; , serif;"><br /></span></span> <span style="line-height: 107%;"><span style="font-family: &quot;times&quot; , &quot;times new roman&quot; , serif;">GLASS, which was launched in 2015 to help achieve the goals of the WHOs Global Action Plan on&nbsp;</span></span><br /><span style="line-height: 107%;"><span style="font-family: &quot;times&quot; , &quot;times new roman&quot; , serif;">Antimicrobial Resistance (AMR) includes establishing country-level surveillance of antibiotic use and resistance. There is a lot of momentum building globally on advancing in-country surveillance and innovation around tracking and transmission interruption. These include the Global AMR collaboration <a href="https://wellcome.ac.uk/press-release/wellcome-and-gates-foundation-support-new-global-body-tackle-superbugs" target="_blank">Hub</a>&nbsp;in Germany (focusing on new drug development), <a href="https://wellcome.ac.uk/news/global-intelligence-superbugs-vital-stop-antibiotic-resistance" target="_blank">SEDRIC</a>&nbsp;(surveillance and epidemiology of drug resistant infections consortium), a new initiative funded by Wellcome Trust aimed to provide technical expertise and knowledge to address barriers with a focus on bringing new technology to bear on big data. In addition the Gates Foundation has contributed in numerous ways, including&nbsp;<a href="https://gcgh.grandchallenges.org/challenge/novel-approaches-characterizing-and-tracking-global-burden-antimicrobial-resistance-0" target="_blank">Grand Challenge Grants</a></span></span>http://haicontroversies.blogspot.com/2018/02/global-antibiotic-resistance.htmlnoreply@blogger.com (scott fridkin)0tag:blogger.com,1999:blog-8066238290370557389.post-2730305643250265663Wed, 07 Feb 2018 20:56:00 +00002018-02-07T14:58:27.669-06:00communicationNHSNrisk adjustmentCommunicating Complexity<div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-2mpZ54nYhfU/WntlOiQQHyI/AAAAAAAAAEY/3Fh5O-YjGH0H_ubnkLljhlklYbEYjxcFgCLcBGAs/s1600/blog.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="402" data-original-width="640" height="250" src="https://1.bp.blogspot.com/-2mpZ54nYhfU/WntlOiQQHyI/AAAAAAAAAEY/3Fh5O-YjGH0H_ubnkLljhlklYbEYjxcFgCLcBGAs/s400/blog.jpg" width="400" /></a></div><br /><span style="font-family: &quot;helvetica neue&quot; , &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span><br /><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">Healthcare quality metrics are such a struggle. &nbsp;We all want metrics that best reflect our efforts to keep patients safe at our institutions, while not penalizing institutions who provide care for patients at higher risk for complications.&nbsp; We also want the data collection burden to be light and the outcome to be simple and easy to understand. When comparisons are going to be made among hospitals of varying sizes, that offer different levels of care, to populations from varying economic and social support systems, we want known risk factors to be taken into consideration. &nbsp;And not just to avoid financial penalties at our hospitals, but also to provide better information to patients.&nbsp; While I doubt that many patients actually use the Hospital Compare data to select a facility (most “choices” are driven by insurance coverage, geography and physician referrals), if they did, it would be nice if the metrics actually steered them toward safer healthcare. <o:p></o:p></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;"><br /></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">And NHSN listened to these concerns, moving to risk adjusted models and the SIR - a summary statistic that accounts for the prevalence of (a few) known risk factors.&nbsp; But as the stakes get higher, limitations to the current risk adjustment models grow increasingly frustrating. Why can’t we make these models better?<o:p></o:p></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;"><br /></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">On the other hand, the move to risk adjusted models has increased the complexity of both understanding and communicating our outcomes, internally among &nbsp;infection prevention program personnel and hospital leadership and externally to the public and consumer organizations. &nbsp;Recent work by Vineet Chopra and his colleagues at UMichigan have been looking at how well we “experts” even understand these metrics ourselves.&nbsp; His most recent evaluation was a survey of SHEA research network members, published in ICHE under the title “Do Experts Understand Performance Measures? A Mixed-Methods Study of Infection Preventionists” (though 80% of respondents were physicians).&nbsp; &nbsp;Respondents were given a table of data about 8 hypothetical hospitals and asked questions about interpreting the presented data and about the impact changes at those facilities might (or might not) have on the data.&nbsp; Of 67 respondents (only 54 of whom answered every question, so a pretty small sample), performance was mixed.&nbsp; Particular difficulty was noted on questions that involved risk adjustment, such as the impact of more G tube use at one hospital on the calculated SIR or the impact of implementing antibiotic coated catheters on the projected number of infections. &nbsp;&nbsp;And this from a group of primarily physician leaders of hospital epidemiology programs, engaged in SHEA, many from academic medical centers. <o:p></o:p></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;"><br /></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">I brought the survey questions to the monthly meeting of all the infection preventionists from across our healthcare system and I am happy to report we did very well!&nbsp; We had quibbles with how some of the questions were worded and we benefitted from being able to talk through the questions together as we formulated our answers. <o:p></o:p></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;"><br /></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">The authors concluded that limitations in understanding the risk adjustment data may make the data ‘less actionable by end users’ and ‘..decision makers’ trying to reduce HAIs.&nbsp; I’m not sure that is true.&nbsp; The SIR does at least provide a fairly simple guidepost of “numbers higher than they should be”. &nbsp;That should be enough to prompt action – but sharing an SIR with leadership and program personnel to develop plans for action requires more in depth understanding than just the SIR itself.&nbsp; It requires knowledge of what factors are included in the risk adjustment model and what are not, the prevalence of all those factors in your population, and which of those factors are actionable/preventable.&nbsp; That more in depth understanding is a bigger challenge and is harder to summarize and communicate in a single metric - especially if you don’t fully understand it yourself.<o:p></o:p></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;"><br /></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">The other issue raised by this complexity, and our own difficulties interpreting and explaining it, is one of trust and transparency with the other ‘end-users’: patients. &nbsp;While we advocate to improve risk adjustment, to make comparisons among facilities more appropriate, some patients and consumer groups feel that we are purposefully obscuring actual numbers of infections in order to hide poor practices.&nbsp; The ‘black box’ from which the SIR emerges can erode much needed trust. <o:p></o:p></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;"><br /></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">Luckily, NHSN heard these concerns as well.&nbsp; Through HICPAC, two new NHSN working groups have been formed: &nbsp;data and definitions (including risk adjustment) and communication. And the communication subgroup is co-led by Dr Vineet Chopra! That group will be discussing better ways to communicate the complex inputs and hopefully understandable outputs both verbally and visually.&nbsp; Good communication provides much needed clarity and builds trust. I look forward to hearing about their work.<o:p></o:p></div><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;"><br /></div><br /><div class="MsoNormal" style="line-height: normal;">PS I especially enjoyed reading the comments in the supplementary material where respondents offered answers to the question “in your opinion, what are the three biggest problems for reliability of quality metric data at your hospital”.&nbsp; I recommend them to everyone. They call out issues with risk adjustment, data collection, definitions etc.&nbsp; A couple of favorites include “some preventable infections are more preventable than others”; “we don’t use quality metric data” ; and “gaming the system; gaming the system; gaming the system”.&nbsp;<o:p></o:p></div>http://haicontroversies.blogspot.com/2018/02/communicating-complexity.htmlnoreply@blogger.com (Hilary Babcock)0tag:blogger.com,1999:blog-8066238290370557389.post-5807356283573477292Sat, 03 Feb 2018 19:52:00 +00002018-02-03T14:08:24.764-06:00case-control studiescohort studiesJanet Lane-ClayponNational Women Physicians DayWomen in Healthcare Epidemiology<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody><tr><td style="text-align: center;"><a href="https://4.bp.blogspot.com/-SmR8kfIv_jI/WnYQ1Mg4NhI/AAAAAAAABhc/rOevOYAbB84RPyvwLiM17VMJ_N5pzWooACLcBGAs/s1600/janet-lane-claypon-1.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><img border="0" data-original-height="750" data-original-width="900" height="166" src="https://4.bp.blogspot.com/-SmR8kfIv_jI/WnYQ1Mg4NhI/AAAAAAAABhc/rOevOYAbB84RPyvwLiM17VMJ_N5pzWooACLcBGAs/s200/janet-lane-claypon-1.jpg" width="200" /></span></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif; font-size: small;">Dr. Janet Lane-Claypon</span></td></tr></tbody></table><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">I'm not a big fan of National [fill-in-the-blank] Days—to me they imply we can ignore the topic on the 364 days that we aren’t supposed to celebrate it. So on <a href="https://nationaldaycalendar.com/national-women-physicians-day-february-3/">National Women Physicians Day</a>, we should vow to better recognize the huge contributions women physicians make every day. That way we might not even need a “day” in the future, and can thus focus instead on preparing for <a href="https://nationaldaycalendar.com/days-2/national-lima-bean-respect-day-april-20/">National Lima Bean Respect Day</a> (April 20).<br /><br />In the field of healthcare epidemiology and infection prevention, the list of women leaders is long--and for me to produce one would be very dangerous because I’m sure it’d be incomplete. Instead I’ll point out that the last two SHEA presidents were women, and the 2019 SHEA president will be our esteemed fellow blogger, Hilary Babcock (congrats again, Hilary!).<br /><br />This also seems like a good day to point interested readers to <a href="https://academic.oup.com/aje/article/160/2/97/76439">this piece</a> about <a href="https://en.wikipedia.org/wiki/Janet_Lane-Claypon">Dr. Janet Lane-Claypon</a>, a pioneering physician-epidemiologist who was the first to employ the now-ubiquitous cohort and case-control study designs we use so often in infection prevention. The <a href="https://academic.oup.com/aje/article/160/2/97/76439">paper was published in 2004</a> but I only recent stumbled on it, and found it a fascinating story about a person I clearly should have learned about during my epidemiology coursework (but didn’t!).<br /><br />I recognize the irony of me posting this from a blog that has a 5:1 male:female ratio. We’ve tried over the years to recruit women to the blog, mostly unsuccessfully. One possible reason (besides the obvious—that we haven’t tried hard enough), is that women physicians put up with substantially more bullshit each day than their male counterparts, and thus have less time for blogging.<br /><br />To our female readership: if you’re interested in contributing to the blog (either with periodic guest posts, or joining the group), please contact one of us. This isn’t limited to physicians: infection preventionists, non-physician epidemiologists, microbiologists, nurses…pretty much anybody with expertise and strong opinions about infection prevention and healthcare epidemiology!</span><br /><div class="MsoNormal"><o:p></o:p></div><style><!-- /* Font Definitions */ @font-face {font-family:"ＭＳ 明朝"; panose-1:0 0 0 0 0 0 0 0 0 0; mso-font-charset:128; mso-generic-font-family:roman; mso-font-format:other; mso-font-pitch:fixed; mso-font-signature:1 134676480 16 0 131072 0;} @font-face {font-family:"ＭＳ 明朝"; panose-1:0 0 0 0 0 0 0 0 0 0; mso-font-charset:128; mso-generic-font-family:roman; mso-font-format:other; mso-font-pitch:fixed; mso-font-signature:1 134676480 16 0 131072 0;} @font-face {font-family:Cambria; panose-1:2 4 5 3 5 4 6 3 2 4; mso-font-charset:0; mso-generic-font-family:auto; mso-font-pitch:variable; mso-font-signature:3 0 0 0 1 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-unhide:no; mso-style-qformat:yes; mso-style-parent:""; margin-top:0in; margin-right:0in; margin-bottom:10.0pt; margin-left:0in; mso-pagination:widow-orphan; font-size:12.0pt; font-family:Cambria; mso-ascii-font-family:Cambria; mso-ascii-theme-font:minor-latin; mso-fareast-font-family:"ＭＳ 明朝"; mso-fareast-theme-font:minor-fareast; mso-hansi-font-family:Cambria; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:"Times New Roman"; mso-bidi-theme-font:minor-bidi; mso-fareast-language:JA;} .MsoChpDefault {mso-style-type:export-only; mso-default-props:yes; font-family:Cambria; mso-ascii-font-family:Cambria; mso-ascii-theme-font:minor-latin; mso-fareast-font-family:"ＭＳ 明朝"; mso-fareast-theme-font:minor-fareast; mso-hansi-font-family:Cambria; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:"Times New Roman"; mso-bidi-theme-font:minor-bidi; mso-fareast-language:JA;} .MsoPapDefault {mso-style-type:export-only; margin-bottom:10.0pt;} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.25in 1.0in 1.25in; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.WordSection1 {page:WordSection1;} </style> --&gt;http://haicontroversies.blogspot.com/2018/02/women-in-healthcare-epidemiology.htmlnoreply@blogger.com (Dan Diekema)2tag:blogger.com,1999:blog-8066238290370557389.post-6401143641606764699Thu, 25 Jan 2018 04:16:00 +00002018-01-26T22:57:43.036-06:00Diagnostic StewardshipDiagnostic Stewardship: It's all the rage!<span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">Dan Morgan <a href="http://haicontroversies.blogspot.com/2017/08/diagnostic-stewardship.html">recently blogged here</a> about diagnostic stewardship, referencing a <a href="https://jamanetwork.com/journals/jama/article-abstract/2647071">JAMA viewpoint</a> we published last year, and I’ll be presenting on the topic at the Remington Winter Course next month (<a href="https://wintercourseinfectiousdiseasefoundation.wildapricot.org/">join us</a>!). So I wanted to draw attention to an <a href="https://doi.org/10.1017/ice.2017.278">excellent commentary</a> just published in ICHE on diagnostic stewardship for healthcare-associated infections (HAIs), outlining opportunities and challenges. The key table is below.&nbsp;</span><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-Ziak1Nj58Vg/WmlXDohdDiI/AAAAAAAABg0/6Z58ZEHvg-c-ZkDnsHXvlIV_Y5gTYYJygCLcBGAs/s1600/urn_cambridge.org_id_binary_20180115080841497-0560_S0899823X17002781_S0899823X17002781_tab1.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="571" data-original-width="881" height="414" src="https://1.bp.blogspot.com/-Ziak1Nj58Vg/WmlXDohdDiI/AAAAAAAABg0/6Z58ZEHvg-c-ZkDnsHXvlIV_Y5gTYYJygCLcBGAs/s640/urn_cambridge.org_id_binary_20180115080841497-0560_S0899823X17002781_S0899823X17002781_tab1.gif" width="640" /></a></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">Also, in a great example of the need for diagnostic stewardship for HAIs, Clare Rock and colleagues just published </span><a href="https://www.ncbi.nlm.nih.gov/pubmed/29305285" style="font-family: Arial, Helvetica, sans-serif;">this observational study in AJIC</a><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">. They retrospectively reviewed 18 months of surveillance for hospital-onset </span><i style="font-family: Arial, Helvetica, sans-serif;">C. difficile</i><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"> infection (HO-CDI) “LabID events” reported to </span><a href="https://www.cdc.gov/nhsn/index.html" style="font-family: Arial, Helvetica, sans-serif;">NHSN</a><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">. For those not acquainted with the NHSN LabID event metrics, they do not consider patient-level clinical variables—only lab results and admission/testing dates. Of the 490 HO-CDI cases that occurred during the study period, chart review determined that 206 (42%!) of them were not likely to represent “true” CDI. In about half of “untrue” cases there was no significant diarrhea (defined as &gt;= 3 loose stools in 24 hours), in 41% the patient had received a laxative in the prior 48 hours, and in almost 10% of cases the symptom onset was prior to the “hospital-onset” criterion but testing was delayed. The graphs below demonstrate how improved test utilization could have changed their publicly-reported (and reimbursement-linked) HO-CDI rates. Of course the SIR data assumes that no other hospitals implemented similar diagnostic stewardship programs…</span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://3.bp.blogspot.com/-dvdwBCdw070/WmlXPxpNhLI/AAAAAAAABg4/uUrBsXueh10rstacHR2rJkefAvevju81gCLcBGAs/s1600/ymic4639-fig-0001.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="283" data-original-width="816" height="219" src="https://3.bp.blogspot.com/-dvdwBCdw070/WmlXPxpNhLI/AAAAAAAABg4/uUrBsXueh10rstacHR2rJkefAvevju81gCLcBGAs/s640/ymic4639-fig-0001.jpg" width="640" /></a></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">When I talk about diagnostic stewardship to my laboratory colleagues, they often seem a bit puzzled—“OK, please don’t test patients with low pre-test likelihood of disease—isn’t that just diagnostics 101?”. So why is the issue gaining more traction now? I think it’s due to advances in diagnostic technology and changes in health care delivery. Our tests are becoming more sensitive and expansive (e.g. “syndromic” panels that detect dozens of targets in one fell swoop), and at the same time clinicians are seeing more patients in shorter periods of time and have less time to think about the tests they order—leading to more reliance on technology and less reliance on the careful history and exam findings that are required to generate thoughtful assessments of pre-test disease likelihood.&nbsp;</span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">Also I used to trudge 5 miles through 12 inches of snow to get to grade school, and kids these days….</span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">Finally, an apt comic from JCMs <a href="http://jcm.asm.org/content/56/2/e01916-17.full">excellent new micro-comic series</a>:</span><style><!-- /* Font Definitions */ @font-face {font-family:"ＭＳ 明朝"; mso-font-charset:78; mso-generic-font-family:auto; mso-font-pitch:variable; mso-font-signature:1 134676480 16 0 131072 0;} @font-face {font-family:"ＭＳ 明朝"; mso-font-charset:78; mso-generic-font-family:auto; mso-font-pitch:variable; mso-font-signature:1 134676480 16 0 131072 0;} @font-face {font-family:Cambria; panose-1:2 4 5 3 5 4 6 3 2 4; mso-font-charset:0; mso-generic-font-family:auto; mso-font-pitch:variable; mso-font-signature:-536870145 1073743103 0 0 415 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-unhide:no; mso-style-qformat:yes; mso-style-parent:""; margin-top:0in; margin-right:0in; margin-bottom:10.0pt; margin-left:0in; mso-pagination:widow-orphan; font-size:12.0pt; font-family:Cambria; mso-ascii-font-family:Cambria; mso-ascii-theme-font:minor-latin; mso-fareast-font-family:"ＭＳ 明朝"; mso-fareast-theme-font:minor-fareast; mso-hansi-font-family:Cambria; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:"Times New Roman"; mso-bidi-theme-font:minor-bidi; mso-fareast-language:JA;} .MsoChpDefault {mso-style-type:export-only; mso-default-props:yes; font-family:Cambria; mso-ascii-font-family:Cambria; mso-ascii-theme-font:minor-latin; mso-fareast-font-family:"ＭＳ 明朝"; mso-fareast-theme-font:minor-fareast; mso-hansi-font-family:Cambria; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:"Times New Roman"; mso-bidi-theme-font:minor-bidi; mso-fareast-language:JA;} .MsoPapDefault {mso-style-type:export-only; margin-bottom:10.0pt;} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.25in 1.0in 1.25in; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.WordSection1 {page:WordSection1;} </style></div>--&gt;<br /><div class="separator" style="clear: both; text-align: center;"><a href="https://4.bp.blogspot.com/-D1dEVkK659Q/WmlXWUs4ApI/AAAAAAAABg8/Qdpd9PDWOJE8uyK2tdRCsdi-zozIEjyIgCLcBGAs/s1600/F1_large.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="1200" height="640" src="https://4.bp.blogspot.com/-D1dEVkK659Q/WmlXWUs4ApI/AAAAAAAABg8/Qdpd9PDWOJE8uyK2tdRCsdi-zozIEjyIgCLcBGAs/s640/F1_large.jpg" width="478" /></a></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span></div>http://haicontroversies.blogspot.com/2018/01/diagnostic-stewardship-its-all-rage.htmlnoreply@blogger.com (Dan Diekema)0tag:blogger.com,1999:blog-8066238290370557389.post-2527796914682721334Wed, 17 Jan 2018 04:20:00 +00002018-01-16T22:20:45.024-06:00Candida aurisepidemiologyinfection preventionEssential reading on Candida auris<div class="separator" style="clear: both; text-align: center;"><a href="https://2.bp.blogspot.com/-ss4x5vO3NpM/Wl7N-0c8ReI/AAAAAAAABgc/c1cyBFkkgJsWsYt07WNAPRcjxNT-vg2LgCLcBGAs/s1600/F9.large.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="709" data-original-width="1280" height="353" src="https://2.bp.blogspot.com/-ss4x5vO3NpM/Wl7N-0c8ReI/AAAAAAAABgc/c1cyBFkkgJsWsYt07WNAPRcjxNT-vg2LgCLcBGAs/s640/F9.large.jpg" width="640" /></a></div><div><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div><span style="font-family: Arial, Helvetica, sans-serif;">During my intern rotation on the University of Virginia bone marrow transplant unit, I convinced myself that a <i>Candida krusei</i> epidemic was brewing. One of my patients was infected, and the bug was (and is inherently) resistant to fluconazole, a drug that had only recently been introduced (yes, I’m old—the year was 1990). This never really came to pass—despite 30 years of widespread fluconazole use, <i>C. krusei</i> still accounts for &lt; 5% of invasive candidiasis, and outbreaks are rare.&nbsp;</span><div><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div><div><span style="font-family: Arial, Helvetica, sans-serif;">Now, a <i>Candida</i> species that wasn’t even described a decade ago is emerging as a major problem in ICUs around the world. The <i>Candida auris</i> story is fascinating, puzzling, and concerning. For reasons nobody understands, the species emerged (or began to recognized) almost simultaneously on three different continents. Although risk factors for invasive <i>C. auris</i> are similar to those for other causes of invasive candidiasis (ICU stay, antibiotic exposure, device use), it also features high rates of antifungal resistance, persistence on environmental surfaces, resistance to commonly used disinfectants, frequent transmission in ICU environments, and has thus caused several large, difficult-to-control outbreaks.</span></div><div><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div><div><span style="font-family: Arial, Helvetica, sans-serif;">If you want to catch up on this emerging pathogen without spending hours on a literature review, there’s an <a href="http://cmr.asm.org/content/31/1/e00029-17.full">excellent summary publication</a> now out in <i>Clinical Microbiology Reviews</i> from Anna Jeffery-Smith and colleagues. See <a href="http://cmr.asm.org/content/31/1/e00029-17/T4.expansion.html">Table 4</a> for a summary of infection prevention recommendations from UK, US, EU and South Africa.</span><style><!-- /* Font Definitions */ @font-face {font-family:"ＭＳ 明朝"; panose-1:0 0 0 0 0 0 0 0 0 0; mso-font-charset:128; mso-generic-font-family:roman; mso-font-format:other; mso-font-pitch:fixed; mso-font-signature:1 134676480 16 0 131072 0;} @font-face {font-family:"ＭＳ 明朝"; panose-1:0 0 0 0 0 0 0 0 0 0; mso-font-charset:128; mso-generic-font-family:roman; mso-font-format:other; mso-font-pitch:fixed; mso-font-signature:1 134676480 16 0 131072 0;} @font-face {font-family:Cambria; panose-1:2 4 5 3 5 4 6 3 2 4; mso-font-charset:0; mso-generic-font-family:auto; mso-font-pitch:variable; mso-font-signature:3 0 0 0 1 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-unhide:no; mso-style-qformat:yes; mso-style-parent:""; margin-top:0in; margin-right:0in; margin-bottom:10.0pt; margin-left:0in; mso-pagination:widow-orphan; font-size:12.0pt; font-family:Cambria; mso-ascii-font-family:Cambria; mso-ascii-theme-font:minor-latin; mso-fareast-font-family:"ＭＳ 明朝"; mso-fareast-theme-font:minor-fareast; mso-hansi-font-family:Cambria; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:"Times New Roman"; mso-bidi-theme-font:minor-bidi; mso-fareast-language:JA;} .MsoChpDefault {mso-style-type:export-only; mso-default-props:yes; font-family:Cambria; mso-ascii-font-family:Cambria; mso-ascii-theme-font:minor-latin; mso-fareast-font-family:"ＭＳ 明朝"; mso-fareast-theme-font:minor-fareast; mso-hansi-font-family:Cambria; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:"Times New Roman"; mso-bidi-theme-font:minor-bidi; mso-fareast-language:JA;} .MsoPapDefault {mso-style-type:export-only; margin-bottom:10.0pt;} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.25in 1.0in 1.25in; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.WordSection1 {page:WordSection1;} --></style></div>http://haicontroversies.blogspot.com/2018/01/essential-reading-on-candida-auris.htmlnoreply@blogger.com (Dan Diekema)0tag:blogger.com,1999:blog-8066238290370557389.post-7526790063692791422Wed, 27 Dec 2017 18:20:00 +00002017-12-28T11:16:11.683-06:00jamanetherlandsprophylaxisrandomized trialssisurgical site infectionAntibiotic prophylaxis isn't needed for removal of below the knee orthopedic implants?<div class="separator" style="clear: both; text-align: center;"><a href="https://2.bp.blogspot.com/-k_x_lMEXobo/WkPYLZIT8xI/AAAAAAAAChE/Ak5JAgwo1Zg2XW8y5LhSbMfqAU7oHXTPwCEwYBhgL/s1600/weather.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="848" data-original-width="1214" height="223" src="https://2.bp.blogspot.com/-k_x_lMEXobo/WkPYLZIT8xI/AAAAAAAAChE/Ak5JAgwo1Zg2XW8y5LhSbMfqAU7oHXTPwCEwYBhgL/s320/weather.png" width="320" /></a></div>Wow, it has been wicked cold this week and it's only going to get colder. It's so cold that I stayed inside and read JAMA RCTs instead of racing to the mall and fighting for discounted gift wrap. Besides adding to my ID knowledge, perhaps this latest polar vortex is also behind the <a href="https://haicontroversies.blogspot.com/2017/12/the-smoldering-dumpster.html">reduced flammability</a> of the ID profession? One can only hope.<br /><div><br /></div><div>The folks that follow me on twitter know the real reason I'm staying current on JAMA studies is that I've recently accepted a position as an Associate Editor for a new JAMA journal called <a href="https://sites.jamanetwork.com/jamanetworkopen/index.html">JAMA Network Open</a>. This open-access journal will begin accepting manuscripts in early 2018. Get those fingers typing - one way to protect yourself from frostbite...</div><div><br /></div><div>In the Boxing Day issue of JAMA there was a very nice multicenter, double-blind <a href="https://jamanetwork.com/journals/jama/fullarticle/2667070">RCT</a>&nbsp;comparing surgical site infection rates post removal of below-the-knee orthopedic implants in patients receiving 1g cefazolin vs saline placebo. The 470 randomized patients were from 19 hospitals in the Netherlands and patients were excluded if they had active infection, fistula or were receiving antibiotics. Outcomes followed CDC definitions. Implant removal is considered a clean procedure with expected SSI rates of 2 to 3.3%, so apparently antibiotic prophylaxis isn't indicated; although reported SSI rates have been higher in removal vs implantation procedures, so some recommend prophylaxis.</div><div><br /></div><div>Spoiler alert: The study was negative. 13.2% of patients in the cefazolin arm and 14.9% in the placebo arm developed SSI, (absolute risk difference, −1.7 [95% CI, −8.0 to 4.6], P = .60). Results below in Table 2. Thus, with a negative study, I headed to the sample size calculations section where the authors stated that they powered the study with an estimated SSI rate of 3.3% in the cefazolin arm and 10% in the placebo arm based on the SSI rates in clean-contamined procedures and recent Dutch retrospective studies, respectively.<br /><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://2.bp.blogspot.com/-iynqa-Cy2Cs/WkPfyST4llI/AAAAAAAAChY/DDnVyL8zNxItvNC7rhWR2hXtoDMcZQgBgCEwYBhgL/s1600/table%2B2.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="458" data-original-width="1600" height="113" src="https://2.bp.blogspot.com/-iynqa-Cy2Cs/WkPfyST4llI/AAAAAAAAChY/DDnVyL8zNxItvNC7rhWR2hXtoDMcZQgBgCEwYBhgL/s400/table%2B2.png" width="400" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: left;">Few thoughts. First, this is an underpowered study. It's true that they hit their target sample size, but their estimates were completed using rosy expectations for the benefits of cefazolin and were not selected based on clinically meaningful reductions in SSI. Many might think a 2% absolute reduction in SSI is clinically meaningful. Second, the authors suggest that the high rates of SSI might have resulted from very low thresholds for starting antibiotics if there was "the slightest suspicion of a SSI." Since CDC definitions define SSI based on receipt of antibiotic treatment, this behavior could have biased the rates. Finally, deep SSI rates were 0.4% (1 patient) in the cefazolin group and a far higher 2.9% (7 patients) in the placebo group, (absolute risk difference, −2.5 [95% CI, −5.7 to 0.4]). Since the study was powered for the primary outcome, all SSI, not much was made of the big difference in deep SSI.&nbsp;</div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">The end result might be disappointing but this is no discredit to the authors and clinicians behind the study - RCTs are very hard to design and implement &nbsp;- thumbs up for all their efforts. With that said, I would prescribe cefazolin as a peri-operative antibiotic during implant removal below the knee since a 2% absolute reduction in all SSI and a 2.5% reduction in deep SSI are both clinically meaningful benefits. I will then wait for another larger study powered using clinically meaningful SSI targets, including deep SSI.</div><div><br /></div><div><br /></div></div>http://haicontroversies.blogspot.com/2017/12/antibiotic-prophylaxis-isnt-needed-for.htmlnoreply@blogger.com (Eli Perencevich)0tag:blogger.com,1999:blog-8066238290370557389.post-8340570637805893838Wed, 20 Dec 2017 21:13:00 +00002017-12-20T22:45:41.309-06:00annual match day messdumpster fireIDSAThe smoldering dumpster<div class="separator" style="clear: both; text-align: center;"><a href="https://2.bp.blogspot.com/-190UVITi8g8/WjrQ1EZudTI/AAAAAAAABf8/p-WwbuPSoI4KsvTM9VVbimSHNWBt2E5pQCLcBGAs/s1600/6ostrttysxsy.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="1600" data-original-width="1200" height="320" src="https://2.bp.blogspot.com/-190UVITi8g8/WjrQ1EZudTI/AAAAAAAABf8/p-WwbuPSoI4KsvTM9VVbimSHNWBt2E5pQCLcBGAs/s320/6ostrttysxsy.jpg" width="240" /></a></div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">I’m a bit delayed this year in commenting upon the ID Match results—go </span><a href="http://haicontroversies.blogspot.com/search/label/annual%20match%20day%20mess" style="font-family: Arial, Helvetica, sans-serif;">here</a><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"> for our prior posts on this topic (and the broader issues affecting recruitment into our specialty).</span><br /><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">IDSA has a <a href="http://newsmanager.commpartners.com/idsa/issues/2017-12-15/9.html">good summary of the results</a>, and the figures below are taken from that article. The overall message is: the <a href="http://haicontroversies.blogspot.com/2014/12/infectious-diseases-and-terrible.html">dumpster fire</a> is no longer raging, but the dumpster is still smoldering! We’ve basically held steady since the new <a href="http://haicontroversies.blogspot.com/2016/12/id-match-2017-turning-point-or-artifact.html">“all-in” Match started last year</a>, with similar percentages of programs and positions filled.&nbsp;</span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">How to interpret the numbers? I think the “all-in” rules have reduced some (most?) of the outside-the-match ‘strategery’ that some programs and applicants were practicing. Thus after a couple years of “all-in”, we have a more accurate picture of the supply-demand relationship for ID training. This picture is far from pretty—a third of programs are going unfilled, representing one in five of our training spots. Clearly, “train longer to make less” is still a difficult reality to overcome, even for a specialty as fascinating and fulfilling as ID.</span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://2.bp.blogspot.com/-u_AxIKlaSFw/WjrQ38iof7I/AAAAAAAABgA/fVWnrAtvzvsH7mAuA9JQB84h8vOMLYl4wCEwYBhgL/s1600/Chart1.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="288" data-original-width="480" height="384" src="https://2.bp.blogspot.com/-u_AxIKlaSFw/WjrQ38iof7I/AAAAAAAABgA/fVWnrAtvzvsH7mAuA9JQB84h8vOMLYl4wCEwYBhgL/s640/Chart1.png" width="640" /></a></div><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-LaNsa-deWAs/WjrQ7JKV9NI/AAAAAAAABgE/E0EVy90WbfQHh9R4_-AiLWyNi4huqV4TACEwYBhgL/s1600/Chart2.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="289" data-original-width="481" height="384" src="https://1.bp.blogspot.com/-LaNsa-deWAs/WjrQ7JKV9NI/AAAAAAAABgE/E0EVy90WbfQHh9R4_-AiLWyNi4huqV4TACEwYBhgL/s640/Chart2.png" width="640" /></a></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">So we have a lot of progress to make, and it will have to be made against some pretty stiff headwinds. Easily lost in the numbers is the substantial proportion of positions filled by international medical graduates. This is a great thing in my view, bringing diverse experience and perspective to our programs—but it also makes demand for ID training highly vulnerable to corrosive political forces that may </span><a href="http://money.cnn.com/2017/12/15/technology/h1b-visa-spouses-h4-trump/index.html" style="font-family: Arial, Helvetica, sans-serif;">make it less inviting</a><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"> to come to the U.S. for training and employment. If IMG numbers fall, the dumpster fire will rage anew.</span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">Finally, the political landscape will undoubtedly also shape the U.S. healthcare system in ways that are unpredictable, but which could reverse some of the trends favorable to ID (e.g. focus on population health and value, with requirements that promised to provide more fulfilling job options for ID—stewardship and infection prevention among them). The strong anti-regulatory mood of the current administration, along with increases in the uninsured population, could reduce incentives for healthcare systems to invest heavily in quality and safety.&nbsp;</span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">To sum up, this year’s match should serve as a continued call-to-action, as we still have huge challenges ahead as a specialty.</span><style><!-- /* Font Definitions */ @font-face {font-family:"ＭＳ 明朝"; panose-1:0 0 0 0 0 0 0 0 0 0; mso-font-charset:128; mso-generic-font-family:roman; mso-font-format:other; mso-font-pitch:fixed; mso-font-signature:1 134676480 16 0 131072 0;} @font-face {font-family:"ＭＳ 明朝"; panose-1:0 0 0 0 0 0 0 0 0 0; mso-font-charset:128; mso-generic-font-family:roman; mso-font-format:other; mso-font-pitch:fixed; mso-font-signature:1 134676480 16 0 131072 0;} @font-face {font-family:Cambria; panose-1:2 4 5 3 5 4 6 3 2 4; mso-font-charset:0; mso-generic-font-family:auto; mso-font-pitch:variable; mso-font-signature:3 0 0 0 1 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-unhide:no; mso-style-qformat:yes; mso-style-parent:""; margin-top:0in; margin-right:0in; margin-bottom:10.0pt; margin-left:0in; mso-pagination:widow-orphan; font-size:12.0pt; font-family:Cambria; mso-ascii-font-family:Cambria; mso-ascii-theme-font:minor-latin; mso-fareast-font-family:"ＭＳ 明朝"; mso-fareast-theme-font:minor-fareast; mso-hansi-font-family:Cambria; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:"Times New Roman"; mso-bidi-theme-font:minor-bidi; mso-fareast-language:JA;} .MsoChpDefault {mso-style-type:export-only; mso-default-props:yes; font-family:Cambria; mso-ascii-font-family:Cambria; mso-ascii-theme-font:minor-latin; mso-fareast-font-family:"ＭＳ 明朝"; mso-fareast-theme-font:minor-fareast; mso-hansi-font-family:Cambria; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:"Times New Roman"; mso-bidi-theme-font:minor-bidi; mso-fareast-language:JA;} .MsoPapDefault {mso-style-type:export-only; margin-bottom:10.0pt;} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.25in 1.0in 1.25in; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.WordSection1 {page:WordSection1;} </style></div>--&gt;http://haicontroversies.blogspot.com/2017/12/the-smoldering-dumpster.htmlnoreply@blogger.com (Dan Diekema)3tag:blogger.com,1999:blog-8066238290370557389.post-8935394413443774515Sun, 03 Dec 2017 18:14:00 +00002017-12-03T12:14:45.487-06:00gift ideainfection preventiontextbookHoliday gift idea!<div class="separator" style="clear: both; text-align: center;"><a href="https://4.bp.blogspot.com/-qyVoTQJDMec/WiQ8ld_3bDI/AAAAAAAABfg/9HwfjY49QGAZtNFb8hHpY5LVmEjYRsEiwCLcBGAs/s1600/image1.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="1200" data-original-width="1600" height="240" src="https://4.bp.blogspot.com/-qyVoTQJDMec/WiQ8ld_3bDI/AAAAAAAABfg/9HwfjY49QGAZtNFb8hHpY5LVmEjYRsEiwCLcBGAs/s320/image1.jpg" width="320" /></a></div><span style="font-family: Arial, Helvetica, sans-serif;">Anyone who practices hospital infection prevention knows how many “data gaps” exist—gaps that make it very difficult to decide which approaches ought to be implemented in your own facility. Should we institute a no-touch disinfection technology? Implement universal decolonization? Use gowns and gloves for all ICU patients? Spend money on an automated hand hygiene monitoring system? Establish a bare-below-the-elbows attire policy? Invest in antimicrobial impregnated textiles (curtains, scrubs, etc.)? Recommend probiotics for selected patient populations?<br /> <br />In the absence of definitive studies, we want carefully considered opinions from smart people who have a wealth of experience in infection prevention. Right?<br /> <br />So if you’re looking for holiday gift ideas for your favorite hospital epidemiologist or infection preventionist, check out this <a href="http://www.springer.com/us/book/9783319609782">new textbook</a>: “<i>Infection Prevention: New Perspectives and Controversies</i>”, edited by our friends <a href="http://commentary-gonzalo86.blogspot.com/">Gonzalo Bearman</a>, <a href="https://www.mcw.edu/Infectious-Diseases/Faculty/Silvia-Munoz-Price-MD-PhD.htm">Silvia Munoz-Price</a>, <a href="http://www.medschool.umaryland.edu/profiles/Morgan-Daniel/">Dan Morgan</a> and <a href="http://califesciences.org/rm-md/">Rekha Murthy</a>. The text is a nice companion to this blog—in addition to covering all the above questions (and more), the chapters are generally concise, well-written and appropriately referenced. The emphasis is not on being encyclopedic, but on addressing the top-of-mind issues that hospital epidemiologists and infection preventionists deal with most often.</span><div><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div><div><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>http://haicontroversies.blogspot.com/2017/12/holiday-gift-idea.htmlnoreply@blogger.com (Dan Diekema)0tag:blogger.com,1999:blog-8066238290370557389.post-4446154651149505383Tue, 14 Nov 2017 13:05:00 +00002017-11-15T21:17:02.534-06:00antimicrobial stewardshipethnographyfocus groupqualitative studystewardshipsurgerysurgical site infectionward roundsShould surgeons be allowed to prescribe antibiotics without assistance?<i>It's the end of a long day on the ID consult service. You and the team have decided to recommend switching antibiotics on a post-op cardiac surgery patient since the S. aureus susceptibilities have returned and you'd prefer cefazolin over vancomycin for her MSSA bacteremia. The team text messages the primary surgical team and the intern meets the team in the ICU. You overhear the ID fellow's discussion with the surgical intern, who appears to not know the patient and who can't get approval from the senior resident, CT surgery fellow or the attending to make the antibiotic change since the whole team is scrubbed in the OR.</i><br /><i><br /></i><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-X3lcjXcbvjQ/WgshrU3yTaI/AAAAAAAACgI/yCciokRRvekPaNNrwyVmhupbdQIYhKxkACLcBGAs/s1600/OR.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="948" data-original-width="844" height="320" src="https://1.bp.blogspot.com/-X3lcjXcbvjQ/WgshrU3yTaI/AAAAAAAACgI/yCciokRRvekPaNNrwyVmhupbdQIYhKxkACLcBGAs/s320/OR.png" width="284" /></a></div><div style="text-align: center;"><i><br /></i></div><i><br /></i>The above scenario is all too familiar to those who practice infectious diseases, and to be fair it could apply to other procedure-based subspecialties. But the question arrises, if only oncologists can prescribe chemotherapy, why is it that everyone is allowed to prescribe antibiotics? Is this really what is best for our patients? Yes, this is currently a controversial topic but these are the types of questions we need to ask if we're going to respond to the antimicrobial resistance crisis.<br /><br />A group of researchers in the UK led by Esmita Charani and <a href="http://www.imperial.ac.uk/people/alison.holmes">Alison Holmes</a> began exploring the effects of culture and team dynamics on antimicrobial prescribing during surgical ward rounds and the results of their <a href="http://www.sciencedirect.com/science/article/pii/S1198743X17301829?via%3Dihub">ethnographic study</a> left me convinced that we must develop ways to improve antimicrobial prescribing on surgical services.<br /><br />The research team observed the antimicrobial prescribing decision making of six surgical teams over a 3-month period. These included observation of 30 ward rounds and face-to-face, semi-structured interviews of 13 clinicians (5 consultant/attending surgeons, 3 registrars/residents, 2 nurses, 2 junior doctors/interns and the ward pharmacist). The qualitative analysis identified 4 key themes that influence antibiotic prescribing: (1) working in a constant state of flux; (2) communication jigsaw; (3) delegating antibiotic management; and (4) the need for an intervention. Here are a few quotes from the study:<br /><br /><i><b>Constant flux: </b>There is a hierarchy as to who leads ward rounds (WR), but this is a shifting hierarchy whereby people are promoted or demoted from their position based on who is present on the WR...if the surgeon leading the WR is called away, for example to the OR, the line of authority shifts downwards and people must act up, for example the registrar takes on the role of the surgeon, the junior doctor ‘becomes’ the registrar and the medical student ‘becomes’ the junior doctor.</i><br /><i><br /><b>Communication jigsaw: </b>WRs are often rushed, interrupted and dispersed and reconvened because of demands for the senior team to be in the OR. The constant disruption and people leaving and joining the WR means that members of staff will rarely be present for the entire WR. Because of being constantly split between the OR and the ward, communication within the surgical team occurs across different platforms. Key decisions are made, recorded and communicated not necessarily in medical health records but on handover sheets, text messaging, and applications on smartphones (e.g. WhatsApp).&nbsp;<b>On many occasions a patient was thought to be on antibiotics by the team, and after further queries in notes and charts was found not to be on them, and vice versa.</b></i><br /><i><b><br /></b><b>Delegating antibiotic management:&nbsp;</b>Surgeons tended to see the core elements of their role as relating to the surgical management of their patients, a role that is performed in the OR. The lack of priority given to antibiotic decision making is compounded by a lack of expertise, resulting in responsibility for antibiotic decisions being commonly delegated to others.</i><br /><i><br /><b>The need for intervention:&nbsp;</b>The need and expectation to intervene means that often antibiotics are initiated for patients with no or little evidence of infection, but a high plausibility of infection in the minds of the surgeons. This process is rationalized by the surgeons as being an extension of their roles as ‘interventionists’. In the absence of evidence of infection what drives antibiotic decision making is a risk of failure, and a risk of blame. <b>What is considered unique in surgery is that a patient has to be well enough to be able to undergo an operation, therefore any deterioration postoperatively is assumed to be a consequence of the surgery, and the decisions of the surgeon, and not the patient's underlying illness. These concerns drive a more conservative approach to antibiotic decision making leading to unnecessary and prolonged courses of antibiotics.</b></i><br /><i><b><br /></b></i>None of these points will appear very surprising to anyone who has cared for patients on a surgical service. However, the authors are to be commended for the care with which they completed this study and the wonderful structure they provided to the domains that influence antimicrobial prescribing. I agree with their assessment that <i><b>"there is a need to explicitly assign the responsibility for antibiotic management of the surgical patient to a responsible, individual with necessary expertise</b>... Diagnosis and treatment of infections is a specialty that requires expertise and training, therefore this is an opportunity to develop, with support from specialist microbiology laboratory and staff, a role for a clinician(s) responsible for perioperative antibiotic management. This will help to strengthen the antibiotic management for surgical patients and has the potential to facilitate continuity of care and to help overcome the substantial gaps in communication that have been identified in this study...The time is right to question whether we need to address the gap in antibiotic prescribing for surgical patients by developing this specific perioperative clinician role to manage infections. This is of critical importance considering the rising challenge of antibiotic resistance in postoperative patients."</i><br /><br />http://haicontroversies.blogspot.com/2017/11/should-surgeons-be-allowed-to-prescribe.htmlnoreply@blogger.com (Eli Perencevich)6tag:blogger.com,1999:blog-8066238290370557389.post-3671447244098697646Fri, 03 Nov 2017 16:20:00 +00002017-11-03T11:20:15.965-05:00CDCcongressPrevention and Public Health FundThey will never stop...<div class="separator" style="clear: both; text-align: center;"><a href="https://3.bp.blogspot.com/-3nL9N5tARm8/WfyXEhetYwI/AAAAAAAABfE/R1RMDDD5_gMa62U-NDNAXe42xyZW8sYSACLcBGAs/s1600/US.capitol.building.wash_.DC_-800x445.jpeg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="445" data-original-width="800" height="222" src="https://3.bp.blogspot.com/-3nL9N5tARm8/WfyXEhetYwI/AAAAAAAABfE/R1RMDDD5_gMa62U-NDNAXe42xyZW8sYSACLcBGAs/s400/US.capitol.building.wash_.DC_-800x445.jpeg" width="400" /></a></div><div><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div><span style="font-family: Arial, Helvetica, sans-serif;">....trying to kill the Prevention and Public Health fund. We’ve blogged about this before, <a href="http://haicontroversies.blogspot.com/2012/03/when-did-cdc-funding-become-oxymoron.html">here</a>, <a href="http://haicontroversies.blogspot.com/2012/03/im-madder-than-giraffe-with-sore-throat.html">here</a>, <a href="http://haicontroversies.blogspot.com/2012/11/prevention-and-public-health-fund-still.html">here</a>, <a href="http://haicontroversies.blogspot.com/2013/04/prevention-who-needs-it.html">here</a>, <a href="http://haicontroversies.blogspot.com/2013/04/prevention-fund-love-finally.html">here</a>, and sadly, again today.</span><div><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div><div><span style="font-family: Arial, Helvetica, sans-serif;">The House of Representatives <a href="http://talkingpointsmemo.com/dc/house-republicans-chip-vote-aca">just voted to reauthorize the Children’s Health Insurance Program (CHIP)</a>, which is a good thing—but decided to pay for it with cuts to Medicare and with a huge slash to the Prevention and Public Health fund, which is a very bad thing that will harm many effective prevention efforts. Here is <a href="https://www.hhs.gov/open/prevention/index.html">a list</a> of what this fund supports, including expansion of laboratory capacity to detect and respond to emerging infections and antimicrobial resistance, and improvement of state public health infrastructure to detect and prevent healthcare-associated infections across all health care settings.</span></div><div><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div><div><span style="font-family: Arial, Helvetica, sans-serif;">Meanwhile, our Congress is also planning a <a href="https://www.washingtonpost.com/business/economy/the-gops-bill-is-a-sensible-framework--but-still-a-deficit-exploding-tax-cut-for-the-rich-and-corporations/2017/11/02/28b3688c-bffe-11e7-959c-fe2b598d8c00_story.html">massive reduction in corporate taxes with no plan to pay for it</a> (besides adding to the deficit).</span></div><div><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div><div><span style="font-family: Arial, Helvetica, sans-serif;">Priorities!</span></div><div><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>http://haicontroversies.blogspot.com/2017/11/they-will-never-stop.htmlnoreply@blogger.com (Dan Diekema)0tag:blogger.com,1999:blog-8066238290370557389.post-1763462070381378409Tue, 31 Oct 2017 13:51:00 +00002017-10-31T11:29:45.014-05:00contact precautionsde-implmentationepidemiologyNEJMnoninferioritystatisticsDe-implementation and Noninferiority in Infection Control StudiesDe-implementation or "stopping practices that lack supporting evidence" is a popular topic in infection control circles. In fact, just yesterday I read a discussion where the authors suggested we no longer need to practice hand hygiene <u>after</u> removing gloves when caring for patients with CDI. I guess there aren't randomized trials - you can't be serious!<br /><br />Which brings me to a <a href="http://www.nejm.org/doi/full/10.1056/NEJMra1510063">recent review</a> in the NEJM by Laura Mauri and Ralph D'Agostino titled "Challenges in the Design and Interpretation of Noninferiority Trials." &nbsp;This review is very well written - perhaps required reading for epidemiology students well written. In infection control, it is important to recognize that most de-implementation studies are really non-inferiority trials. For example, when we discontinue contact precautions, we are really suggesting that "stopping contact precautions" is non-inferior to continuing contact precautions in preventing MDRO transmission - of course ignoring that compliance with contact precautions is probably so poor that they are basically the same intervention!<br /><br />In the contact precautions example, we would be testing whether stopping contact precautions "is not worse than the control (continuing contact precautions) by an acceptably small amount, with a given degree of confidence." The null hypothesis would be that discontinuing contact precautions leads to higher transmission of MDRO (i.e. is worse) and rejection of the null hypothesis is used to support the claim that discontinuing CP is noninferior. Here I suggest you stare at Figure 1 for a bit (probably easier to read in the paper with the description of each condition, but I have included it below anyway)<br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://2.bp.blogspot.com/-k-A30N9QT4E/Wfh7c7XXykI/AAAAAAAACfs/0chryWR_QsUwEc96lsaXx7KdYSEogcuHACLcBGAs/s1600/nejmra1510063_f1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="739" data-original-width="1500" height="315" src="https://2.bp.blogspot.com/-k-A30N9QT4E/Wfh7c7XXykI/AAAAAAAACfs/0chryWR_QsUwEc96lsaXx7KdYSEogcuHACLcBGAs/s640/nejmra1510063_f1.jpg" width="640" /></a></div><br />Further discussion about the design and analysis of these trials is way beyond the scope of a humble blog post; however, the authors include nice descriptions of methods for deriving noninferiority margins, the "constancy assumption" and statistical analysis approaches. But their 6th and 7th components of noninferiority trials are worth mentioning from an infection control standpoint:<br /><br />6) Adequate ascertainment of outcomes: The authors write that <i>"incomplete or inaccurate ascertainment of outcomes, as a result of loss to follow-up, treatment crossover or nonadherence, or outcomes that are difficult to measure or subjective, may cause the treatments being compared to falsely appear similar."</i> &nbsp;I would suggest that studies that seek to de-implement contact precautions that do not include admission/discharge surveillance cultures seeking to detect transmission events fail this criteria.<br /><br />7) Issues with "Intention-to-Treat" in noninferiority designs: In a superiority studies (typical RCTs), intention-to-treat analysis, where anyone who receives the treatment is included even if they get one dose, is the gold standard. The authors write:<i>&nbsp;"In a noninferiority study, however, if some patients did not receive the full course of the assigned treatment, an intention-to-treat analysis may produce a bias toward a false positive conclusion of noninferiority by narrowing the difference between the treatments. In some instances, a per-protocol analysis, which excludes patients who did not meet the inclusion criteria or did not receive the randomized, per-protocol assignment, may be preferable in a noninferiority trial. However, a per-protocol analysis may include fewer participants and introduce postrandomization bias. In general, both the intention-to-treat and per-protocol data sets are important. We suggest analyzing both sets and examining the results for consistency."</i><br /><br />Just some things to think about as we read the coming wave of de-implementation studies in infection control including diagnostic stewardship.<br /><br /><br />http://haicontroversies.blogspot.com/2017/10/de-implementation-and-noninferiority-in.htmlnoreply@blogger.com (Eli Perencevich)0tag:blogger.com,1999:blog-8066238290370557389.post-5929864702265824623Mon, 16 Oct 2017 05:05:00 +00002017-12-27T14:03:32.733-06:00pay for performancepublic reporting of HAIssurveillanceWrong answerThis morning I stumbled upon this piece, <i>Wrong Answer</i> (free full text <a href="https://www.newyorker.com/magazine/2014/07/21/wrong-answer">here</a>), by Rachel Aviv in The New Yorker. It's an old article from 2014, but a wonderfully written, compelling, sad tale. It's the story of how high stakes standardized testing of middle school students in economically disadvantaged neighborhoods in Atlanta led to cheating by teachers. It focuses on Damany Lewis, a superb teacher totally committed to his students, who tirelessly worked to improve his students' math knowledge and was successful in doing so, but not successful enough to hit an unreachable goal. Responding to increasing pressure to raise testing scores, he and other teachers began to change the answers on students' tests. We all know that cheating is unethical, and at first glance I bet most of us would argue to punish those involved, but read this entire piece (warning: it's long), and you're likely to soften your stance. The consequences of not meeting unreasonable targets were so severe that the teachers felt compelled to cheat in the best interest of their students.<br /><br />Now take this article from the education setting into the world of healthcare epidemiology, and if you're like me, there will be chills going down your spine as you read it. It should be required reading for anyone who works in healthcare quality or the key stakeholders in this space, from those at the front lines, to those who work in professional societies, and to those who create policy at the state or national level. There are also lessons here for patients and patient advocates.<br /><br /><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody><tr><td style="text-align: center;"><a href="https://4.bp.blogspot.com/-XHJwV6Cwsws/WeOy0CQOOkI/AAAAAAAAB-c/QLs9FzcY0ywh2wXmhjAGa0VlDvE5AnQ7wCLcBGAs/s1600/Donald_T_Campbell-lg.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="438" data-original-width="300" height="320" src="https://4.bp.blogspot.com/-XHJwV6Cwsws/WeOy0CQOOkI/AAAAAAAAB-c/QLs9FzcY0ywh2wXmhjAGa0VlDvE5AnQ7wCLcBGAs/s320/Donald_T_Campbell-lg.jpg" width="219" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">Donald Campbell</td></tr></tbody></table>What happened in Atlanta shouldn't surprise us. In 1979, <a href="https://en.wikipedia.org/wiki/Donald_T._Campbell">Donald Campbell</a>, a psychologist, published a paper, the crux of which has become known as <a href="https://en.wikipedia.org/wiki/Campbell%27s_law">Campbell's law</a>. I wasn't aware of this until I read Aviv's article. It states:&nbsp;<i>"The more any quantitative social indicator is used for social decision-making, the more subject it will be to corruption pressures and the more apt it will be to distort and corrupt the social processes it is intended to monitor."</i>&nbsp;Moving this to our world, you can delete the word "social" in Campbell's law and take a look at Dan Sexton's commentary, <i>Casablanca Redux</i>, from 2012. Here's an excerpt:<br /><blockquote class="tr_bq"><i>Our informal discussions with other hospital epidemiologists, our experience in evaluating the source of infection in hundreds of bacteremic intensive care unit (ICU) patients, and common sense have led us to suspect that many hospitals do not accurately report their true rates of CLABSI, using current NHSN definitions. In some cases this may reflect an unwillingness of local staff to accept these definitions as accurate or fair; in other situations it may reflect an unconscious desire to hedge or reduce their rate of CLABSI to avoid criticism and negative consequences from their local supervisors in the press, clinicians, or the general public who review their publicly reported data... If clinicians inappropriately or illogically fear or anticipate negative feedback about the rate of CLABSI in their institutions, they may consciously or subconsciously fail to obtain blood culture results for every patient with a possible or likely BSI. Simply put: no culture equals no infection, using standard definitions of CLABSI.&nbsp;</i></blockquote>At some level, we are all complicit in this. And depending on the action, it may not be the wrong thing to do. In fact, it may benefit the patient. For example, better diagnostic stewardship in the form of appropriately ordering fewer urine cultures, not only lowers CAUTI rates but reduces antibiotic utilization with several resultant benefits. Still it's important to note that the primary impetus for this was to lower HAI rates. We take into consideration how a new diagnostic test may impact HAI rates and may even allow that to impact the decision to implement (see an excellent paper by Dan on this <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5377856/">here</a>). We may allow clinicians to censor infections that infection preventionists have detected even though the cases meet NHSN definitions. And at the extreme, hospitals may engage in practices that may harm patients in order to reduce publicly reported HAI rates. In a recent <a href="http://journals.lww.com/academicmedicine/Abstract/2017/07000/_It_Feels_Like_a_Lot_of_Extra_Work____Resident.42.aspx">publication</a> on how physicians in training view quality initiatives, a dirty secret was elicited from a resident during a focus group at an academic medial center:&nbsp;<i>“There’s like the central line infection protocols…. If you suspect that anybody has any type of bacteremia, you don’t do a blood culture, you just do a urine culture and pull the lines … we just don’t even test for it because the quality improvement then like marks you off.”&nbsp;</i><br /><i><br /></i>While reading Rachel Aviv's paper, I wondered: Do we ever ignore results (i.e., infection rates) that seem too good to be true like the educational administrators in Atlanta did? Do we critically analyze surprisingly good results to the same degree as we do surprisingly bad results? In Damany Lewis' case did the end justify the means? Is there ever a situation where I could be pushed to a similar point as Lewis?<br /><br /><div>The Atlanta school system harmed students and teachers in a thoughtless quest to improve quality. There were no winners. Sadly, the response to the cheating scandal was to raise the stakes for test scores even higher. With pay for performance the same is happening in health care.</div><br /><i><br /></i><i><br /></i>http://haicontroversies.blogspot.com/2017/10/wrong-answer.htmlnoreply@blogger.com (Mike Edmond)2tag:blogger.com,1999:blog-8066238290370557389.post-4739370707343115120Sun, 15 Oct 2017 14:00:00 +00002017-10-15T09:53:56.930-05:00ABATEchlorhexidinedecolonizationIDWeekmupirocinSusan HuangChlorhexidine bathing outside the ICU: Await the ABATE!<div class="separator" style="clear: both; text-align: center;"><a href="https://2.bp.blogspot.com/-iervP1nENo0/WeLPpXWnlLI/AAAAAAAABes/0EqXabs_Ky8-sRrsTGCJwyDotfu_w2zuQCLcBGAs/s1600/abate_fa_tag-copy-2-300x190.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="190" data-original-width="300" src="https://2.bp.blogspot.com/-iervP1nENo0/WeLPpXWnlLI/AAAAAAAABes/0EqXabs_Ky8-sRrsTGCJwyDotfu_w2zuQCLcBGAs/s1600/abate_fa_tag-copy-2-300x190.jpg" /></a></div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">Daily chlorhexidine (CHG) bathing has become routine in many ICUs. Given that more healthcare-associated infections (HAIs) (including more central-line associated bloodstream infections (CLABSIs)) <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6008a4.htm">occur outside of the ICU</a>, many hospitals have also implemented this practice on general medicine and surgical wards. However, to this point there are few data to support the effectiveness of CHG bathing outside of ICUs.&nbsp;</span><br /><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">So I was very excited to hear Susan Huang present <a href="https://idsa.confex.com/idsa/2017/webprogram/Paper64645.html">the results of the <b>A</b>ctive <b>Bat</b>hing to <b>E</b>liminate Infection (ABATE) study at IDWeek</a> last week. Similar to the <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1207290">REDUCE MRSA study</a>, this <a href="https://clinicaltrials.gov/ct2/show/NCT02063867">53 hospital cluster-randomized trial</a> took place in the Hospital Corporation of America (HCA) system. Units were randomized to <u>routine care</u> or <u>decolonization</u> (this consisted of daily CHG [4% rinse-off shower or 2% leave-on bed bath] with addition of mupirocin nasal ointment for 5 days if + for MRSA by history or culture/screen) for a 21-month intervention period (after collecting baseline data for 12 months). The primary outcome was MRSA or VRE clinical isolates, and the main secondary outcome was any bloodstream isolate attributed to the unit (for common commensals, 2 or more + cultures).</span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">With the requisite reminder that it is always best to wait for the peer-reviewed publication to make firm conclusions, the results presented at IDWeek suggest the likely take-home from this study: No measurable benefit in the entire population, but significant reductions in MRSA/VRE clinical cultures and bloodstream infection in the subgroup with devices (central lines, midlines, and lumbar drains). This subgroup represented 12% of the study population but accounted for 34% of all MRSA/VRE events and 59% of bloodstream infections. The additional reductions in the decolonization arm for this subgroup (compared with routine care) were 32% for MRSA/VRE cultures and 28% for BSI (both highly statistically significant).&nbsp;</span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">Once published, these findings will leave infection prevention programs with some interesting decisions. A quick take might be, “OK, let’s just use CHG in those non-ICU patients with devices (or just central lines).” However, this isn’t what the ABATE trial evaluated—it showed a substantial reduction in MRSA/VRE/BSI outcomes in patients with devices <i>when everyone else was also receiving CHG</i> (+/- mupirocin). To assume that the decolonization of the non-device population had no beneficial effect on those with devices is to discount any potential role for reduction in pathogen transmission between non-device and device patients. Another tricky question has to do with the role of mupirocin—adding this agent to CHG for known MRSA carriers without knowing how important this component of the intervention was adds some logistical complexity, cost, and antimicrobial resistance concerns (the investigators are also doing the microbiology work to assess for CHG and mupirocin resistance emergence).&nbsp;</span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">We’ll revisit this study once it is published and all the details are available. For now we should congratulate Susan and the entire ABATE trial team for another tremendous contribution!</span><style><!-- /* Font Definitions */ @font-face {font-family:Arial; panose-1:2 11 6 4 2 2 2 2 2 4; mso-font-charset:0; mso-generic-font-family:auto; mso-font-pitch:variable; mso-font-signature:-536859905 -1073711037 9 0 511 0;} @font-face {font-family:"ＭＳ 明朝"; mso-font-charset:78; mso-generic-font-family:auto; mso-font-pitch:variable; mso-font-signature:1 134676480 16 0 131072 0;} @font-face {font-family:"ＭＳ 明朝"; mso-font-charset:78; mso-generic-font-family:auto; mso-font-pitch:variable; mso-font-signature:1 134676480 16 0 131072 0;} @font-face {font-family:Cambria; panose-1:2 4 5 3 5 4 6 3 2 4; mso-font-charset:0; mso-generic-font-family:auto; mso-font-pitch:variable; mso-font-signature:-536870145 1073743103 0 0 415 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-unhide:no; mso-style-qformat:yes; mso-style-parent:""; margin:0in; margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:12.0pt; font-family:Cambria; mso-ascii-font-family:Cambria; mso-ascii-theme-font:minor-latin; mso-fareast-font-family:"ＭＳ 明朝"; mso-fareast-theme-font:minor-fareast; mso-hansi-font-family:Cambria; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:"Times New Roman"; mso-bidi-theme-font:minor-bidi;} .MsoChpDefault {mso-style-type:export-only; mso-default-props:yes; font-family:Cambria; mso-ascii-font-family:Cambria; mso-ascii-theme-font:minor-latin; mso-fareast-font-family:"ＭＳ 明朝"; mso-fareast-theme-font:minor-fareast; mso-hansi-font-family:Cambria; mso-hansi-theme-font:minor-latin; mso-bidi-font-family:"Times New Roman"; mso-bidi-theme-font:minor-bidi;} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.25in 1.0in 1.25in; mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.WordSection1 {page:WordSection1;} --></style></div>http://haicontroversies.blogspot.com/2017/10/chlorhexidine-bathing-outside-icu-await.htmlnoreply@blogger.com (Dan Diekema)0tag:blogger.com,1999:blog-8066238290370557389.post-4939544599163198561Mon, 09 Oct 2017 19:53:00 +00002017-10-09T14:53:31.155-05:00IDWeek 2017 is in the books<br /><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-h4c6b_lk_NY/WdvQNMJrAaI/AAAAAAAAAFk/JcQW5C2ePEIY71k7JbdKGGdWzGYu6c1zgCLcBGAs/s1600/IDWeek.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="140" data-original-width="600" height="147" src="https://1.bp.blogspot.com/-h4c6b_lk_NY/WdvQNMJrAaI/AAAAAAAAAFk/JcQW5C2ePEIY71k7JbdKGGdWzGYu6c1zgCLcBGAs/s640/IDWeek.jpg" width="640" /></a></div><br /><br />I'm back from IDWeek 2017 in San Diego -- always good to reconnect with old friends, meet new colleagues, and hear the latest in infection prevention and antibiotic stewardship science and practice.&nbsp; This year I noted an increase in pro-con and clinical controversies sessions, which I think are so valuable for those of us struggling day-to-day with issues where the evidence base is absent or opinion is conflicting.&nbsp; &nbsp;If you didn't get a chance to attend, fear not, as I am sure there will be more conference-related news emerging over the coming weeks (all 6 of your favorite bloggers made an appearance).&nbsp;<br /><br />Of course, it's never too early to think about next year -- IDWeek 2018 heads back to the left coast, this time it's San Francisco, October 3-7, 2018 (mark your calendars!).&nbsp; I'm among the SHEA contingent for the planning committee (along with Hilary), and we're very interested in program suggestions -- please send them our way.<br /><br />I'll leave you with one meeting tidbit -- Shelley Magill presented the results from the CDC's 2015 HAI Prevalence study, a follow up to their <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1306801">2011 survey that was published in the NEJM</a>.&nbsp; In the 4 years since the first survey (using the same hospitals included previously):<br /><br /><ul><li>The HAI prevalence rate among hospitalized acute care patients fell from 4.1% to 3.2% (a 22% decrease)</li><li>Central line and urinary catheter use were both significantly lower</li><li>Healthcare-associated UTIs and SSIs significantly decreased</li></ul><div>Nice to see some positive news to reflect the extensive HAI prevention efforts nationwide.&nbsp; Of note, antimicrobial use stayed stable, reinforcing the need for increased antibiotic stewardship efforts.&nbsp; Given the enhanced focus in this area, I am hopeful that the next prevalence survey will show improvement on that end as well.</div>http://haicontroversies.blogspot.com/2017/10/idweek-2017-is-in-books.htmlnoreply@blogger.com (Tom Talbot)0tag:blogger.com,1999:blog-8066238290370557389.post-3808755837830581858Tue, 26 Sep 2017 15:26:00 +00002017-10-18T04:37:11.315-05:00CLABSICMSrisk adjustmentssiUnwarping the playing field<div class="separator" style="clear: both; text-align: center;"><a href="https://2.bp.blogspot.com/-RF1ZhbmE5a8/Wcpww765HXI/AAAAAAAAAFI/oY53ia-7nIcd7hMM6W8by6muVfA3EONFgCLcBGAs/s1600/23d1948089163_5602abaa0c220.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="424" data-original-width="600" height="226" src="https://2.bp.blogspot.com/-RF1ZhbmE5a8/Wcpww765HXI/AAAAAAAAAFI/oY53ia-7nIcd7hMM6W8by6muVfA3EONFgCLcBGAs/s320/23d1948089163_5602abaa0c220.jpg" width="320" /></a></div><span style="font-family: &quot;verdana&quot; , sans-serif;"></span><br /><span style="font-family: &quot;verdana&quot; , sans-serif;"></span><br /><span style="font-family: &quot;verdana&quot; , sans-serif;">Easing comfortably into my role as a "blogger," I've realized how easy it is to adopt a few key platform issues that tend to drive one a bit mad.&nbsp; This blog isn't so fond of CAUTI, contact precautions, or devices that blow moist, warm particles over sterile fields (but then again, who is?).&nbsp; We love diagnostic stewardship, influenza vaccination (um, mostly), and fecal transplantation.</span><br /><br /><span style="font-family: &quot;verdana&quot; , sans-serif;"><span style="font-family: &quot;verdana&quot;;">Add advocating for better risk-adjustment of publically-reported HAI performance to my list.&nbsp; A few months ago, I blogged about <a href="https://haicontroversies.blogspot.com/2017/05/the-playing-field-is-still-warped.html">this issue and poor reporting validation by CMS</a>&nbsp;-- now some excellent papers on improving risk adjustment have emerged, both from many FOB (friends of the blog) with senior authorship by Anthony Harris and his group at Maryland.&nbsp; One focuses on <a href="https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/cix431">SSI</a> and one on <a href="https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/effect-of-adding-comorbidities-to-current-centers-for-disease-control-and-prevention-centrallineassociated-bloodstream-infection-riskadjustment-methodology/5EB5B07BE0C5B95C9623E567CBE483DB">CLABSI</a>.&nbsp; Their methodology is very similar and has some key features:</span></span><br /><ul><li><span style="font-family: &quot;verdana&quot;;">They&nbsp;used comorbid conditions that are components of the Charlson and Elixhauser comorbidity indices</span></li><li><span style="font-family: &quot;verdana&quot;;">These conditions were captured by diagnostic discharge coding that&nbsp;<span style="font-family: &quot;verdana&quot;;">are currently routinely collected and submitted to CMS, limiting the data collection burden&nbsp;</span></span></li><li><span style="font-family: &quot;verdana&quot;;">They used conditions identified using Delphi consensus&nbsp;methodology from a survey of ID and infection prevention experts, providing some clinical credibility to the process</span></li></ul><span style="font-family: &quot;verdana&quot;;">The authors examined the model performance and assessed changes in hospital rankings when compared to the traditional NHSN models.&nbsp;For SSI, a model containing procedure type, patient age, race, smoking history, diabetes, liver disease, obesity, renal failure and malnutrition showed good discrimination, and 86% of hospitals changed ranks within the cohort when the risk-adjusted model was used -- with 4 hospitals changing by <u><strong>&gt;10 ranking spots</strong></u>.&nbsp; For CLABSIs within the ICU, a model using coagulopathy, paralysis, renal failure, malnutrition and age showed improved predictability when compared to the NHSN ICU model, and&nbsp;45% of hospitals changed ranking.&nbsp; T<span style="font-family: &quot;verdana&quot;;">he authors note the clear limitations, including some of the challenges with using coded data, but these papers are important advances in the area of publically-reported HAI data.</span></span><br /><br /><span style="font-family: &quot;verdana&quot;;"><span style="font-family: &quot;verdana&quot;;"><span style="font-family: &quot;verdana&quot;;">You can read some of my more detailed thoughts in the <a href="https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/moving-to-a-more-level-playing-field-the-need-for-risk-adjustment-of-publicly-reported-hospital-clabsi-performance/5417915F335EE77ADC0C5E763CA26CA1">accompanying editorial</a> for the CLABSI paper (shameless plug).&nbsp;&nbsp;At a time when there are many consequences for a hospital's performance on these surveillance metrics (e.g. last year my hospital received a draft quality incentive contract from a private insurer that required our large, tertiary care center to have <strong><u>ZERO</u></strong> of the Big 6 reported HAIs, to the tune of several million dollars in incentives), leveling the playing field to adjust for those factors that lead to HAIs that are beyond the control of the hospital is essential.&nbsp; Thankfully, the CDC and HICPAC have recently chartered a new NHSN work group (disclaimer: Hilary and I serve on this group) and the issue of improved risk adjustment seems to be a major emphasis&nbsp;- fingers crossed that the field will start to level soon.</span></span></span>http://haicontroversies.blogspot.com/2017/09/unwarping-playing-field.htmlnoreply@blogger.com (Tom Talbot)2tag:blogger.com,1999:blog-8066238290370557389.post-5532326637460756980Mon, 18 Sep 2017 16:21:00 +00002017-09-19T23:16:36.929-05:00hospital quality indicatorsmortalityMRSApay for performanceStaphylococcus aureusWhen prevention success stagnates? Treat the patient!<div class="separator" style="clear: both; text-align: center;"></div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /><br />Prevention is paramount – I do believe this, and I know that is so much of what healthcare epidemiologist strive for; however we often become very myopic and focus exclusively on “modifiable risk factors.” It is refreshing to read a nicely done epidemiologic study to illustrate what an impact the infectious disease community can have by improving the way we approach patient treatment. When reading the recent <a href="http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2652832" target="_blank">article</a>&nbsp;in JAMA IM by Michihiko Goto and colleagues I was expecting a nice ecologic study showing an impressionistic picture of how improved treatment processes correlate with improved MRSA bacteremia mortality - but our VA colleagues working with big data have painted more of a realistic&nbsp;<table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody><tr><td style="text-align: center;"><a href="https://2.bp.blogspot.com/-QiZM_P1zx_E/WbaylkbYIFI/AAAAAAAAABQ/SiKVWmZl-7QxxMDn8Rrry_2YJgxfo7STQCEwYBhgL/s1600/manet.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="300" data-original-width="454" height="131" src="https://2.bp.blogspot.com/-QiZM_P1zx_E/WbaylkbYIFI/AAAAAAAAABQ/SiKVWmZl-7QxxMDn8Rrry_2YJgxfo7STQCEwYBhgL/s200/manet.jpg" width="200" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;"><div class="MsoNormal">Le Déjeuner sur l’herbe Painting&nbsp;</div><div class="MsoNormal">by Édouard Manet,&nbsp;</div><div class="MsoNormal">1863 Musée d’Orsay, Paris<o:p></o:p></div><div class="MsoNormal">Google Arts &amp; Culture<o:p></o:p></div></td></tr></tbody></table></span><br /><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">than an impressionistic picture.&nbsp;</span><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">Using the VA database, capturing deaths occurring during both the inpatient stay and the post-discharge period, they quantify improved survival at the patient level is driven by improved processes of care for <i>S. aureus</i> bloodstream infection<a href="http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2652832" target="_blank"> (Association of Evidence-Based Care Processes With Mortality in Staphylococcus aureus Bacteremia at Veterans Health Administration Hospitals, 2003-2014 JAMA IM).</a></span><br /><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br />I have been pushing for transitioning efforts to prevent <i>S. aureus</i> (more specifically MRSA) bacteremia to the <a href="https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/civ777" target="_blank">post-discharge</a> setting, worried that the recent reductions observed among hospital-onset MRSA BSI are not being realized in the post-acute care setting. We’re getting stuck; in fact we have been stuck for a while at preventing community-associated MRSA BSI (See figure).&nbsp;</span><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://2.bp.blogspot.com/-MnkWPWpWoP4/Wbaz23b8PwI/AAAAAAAAABY/s32fWcv0z7YcgH4Zcm_n5US4-GEXRSZIQCLcBGAs/s1600/jama%2Bfigures.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="720" data-original-width="960" height="150" src="https://2.bp.blogspot.com/-MnkWPWpWoP4/Wbaz23b8PwI/AAAAAAAAABY/s32fWcv0z7YcgH4Zcm_n5US4-GEXRSZIQCLcBGAs/s200/jama%2Bfigures.jpg" width="200" /></a></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br />Goto and colleagues provide some clarity to preventing deaths related to MRSA BSI (and <i>S. aureus</i> BSI overall) even during periods of prevention stagnation such as we may be in currently. Of note, the incidences of healthcare-associated and hospital-onset MRSA BSI decreased in VHA hospitals between 2003 and 2014, whereas the incidence of CA bacteremia was stable. This is identical to trends illustrated nationally using CDC's EIP data, suggesting the VA analysis may be reflective of what is going on nationally. <br /><br />Goto utilized the national Veterans Health Administration (VHA) health care system to first determine how to best risk adjust mortality; and then determine the independent effect of each of three pillars of guideline directed processes of care for managing <i>S. aureus</i> bacteremia (SAB): (1) appropriate antibiotic therapy, (2) echocardiography, and (3) consultation with ID specialists. They report lower risk-adjusted mortality among patients with SAB when they received (1), (2), or (3), and there was a nice dose-response relationship between the number of care processes and mortality. They estimate <span style="color: #0b5394;">“57.3% of the decrease in risk-adjusted mortality among patients with SAB between 2003 and 2014 could be attributed to increased use of these evidence-based care processes.</span><span style="color: lime;">”</span><br /><br />Their paper also sheds some light on the importance of capturing post-discharge data when quantifying mortality related to processes or infections related to the hospital setting!. Risk-adjusted mortality decreased from 23.5% in 2003 to 18.2% in 2014, regardless of MRSA, MSSA, and place of acquisition (Figure).</span></div><table cellpadding="0" cellspacing="0" class="tr-caption-container" style="float: right; margin-left: 1em; text-align: right;"><tbody><tr><td style="text-align: center;"><a href="https://3.bp.blogspot.com/-hFPdQ15Zepg/Wba1jVeiSwI/AAAAAAAAABo/z0yX5qLGg9wOA2ydC7K9R4tDWc-OikyrgCLcBGAs/s1600/mortality%2Btrend%2Bby%2Bepi.jpg" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" data-original-height="874" data-original-width="1144" height="244" src="https://3.bp.blogspot.com/-hFPdQ15Zepg/Wba1jVeiSwI/AAAAAAAAABo/z0yX5qLGg9wOA2ydC7K9R4tDWc-OikyrgCLcBGAs/s320/mortality%2Btrend%2Bby%2Bepi.jpg" width="320" /></a></td></tr><tr><td class="tr-caption" style="text-align: center;">From Supplemental Figures, Goto et. al.</td></tr></tbody></table><div></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">I was caught by the discrepancy between these mortality rates and the mortality reported by the CDCs <a href="https://www.cdc.gov/abcs/reports-findings/survreports/mrsa14.html" target="_blank">Emerging Infections Program invasive MRSA Surveillance,</a> reported around 12%. The latter is limited to in-hospital or 30 day mortality, whichever comes first. Recent data at IDWeek by one Emerging Infection Program site identified another 30% of deaths among patients with MRSA BSI occurred post-discharge. The Goto paper captures these deaths, making their conclusions more realistic. In addition, their risk adjustment for mortality included over 13 comorbidities, timing of infection, and susceptibility. They did an outstanding job of trying to evaluate the relative importance of each care process while accounting for changes/absence/presence of these underlying predictors of mortality (both inpatient and post-discharge). They even did a sensitivity analysis to account for early deaths, before these care processes could occur. Furthermore, the impact of receiving the care processes was similar regardless if the SAB was hospital-onset or community-onset!<br /><br /><b>The bottom line – following evidence base care processes does save lives.</b>&nbsp;Their&nbsp;analysis support their conclusion that “<span style="color: #0b5394;">there is a need for continued implementation of quality improvement initiatives to increase the adoption of these evidence-based care processes for patients with SAB.”</span> Let’s be bold and call these what they are: performance measures! Here we have a potential metric (proportion of SAB receiving said care process), that are closely linked to improved survival, and can be captured electronically in an objective manner (at least in the VA!)&nbsp;</span><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">improving the reliability of these metrics across facilities. I was glad to find through a google search that </span><a href="http://www.idsociety.org/uploadedFiles/IDSA/Policy_and_Advocacy/Current_Topics_and_Issues/Access_and_Reimbursement/2016/MIPS%202017%20Final%20Rule%20Comment%20Letter%20IDSA.pdf" style="font-family: arial, helvetica, sans-serif;" target="_blank">IDSA</a><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"> recently (December 2016) urged CMS to move in this direction -- although the details of the status of this proposed measure (#407) are not clear to me.</span><br /><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br />While we anticipate novel therapeutics for MRSA BSI including immunotherapy adjuvants or vaccines to become available in the not to distant future; quality improvement efforts in the evidence-based processes of care for SAB now will likely improve our patient’s outcome. I hope we can turn our attention here soon -- and have hospitals rewarded for doing so.</span><br /><div class="MsoNormal"><span style="background: white;"><br /></span></div></div></div></div>http://haicontroversies.blogspot.com/2017/09/when-prevention-success-stagnates-treat.htmlnoreply@blogger.com (scott fridkin)0tag:blogger.com,1999:blog-8066238290370557389.post-4759767611564708430Fri, 15 Sep 2017 17:12:00 +00002017-09-15T21:46:02.608-05:00billingICD-9 codesICHEIDSAsalarySHEAICD Coding and MDRO - If you don't bill for it, it doesn't exist<div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-MItwZH789fw/WbwJIXbKA4I/AAAAAAAACe4/7FcfGAGFK8EUTxztGoZAXFwXPb-C7jk_ACLcBGAs/s1600/icd9-to-icd10.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="298" data-original-width="383" height="248" src="https://1.bp.blogspot.com/-MItwZH789fw/WbwJIXbKA4I/AAAAAAAACe4/7FcfGAGFK8EUTxztGoZAXFwXPb-C7jk_ACLcBGAs/s320/icd9-to-icd10.jpg" width="320" /></a></div><div class="separator" style="clear: both; text-align: center;"><br /></div>Fact 1: Infectious Disease specialists are among <a href="http://healthaffairs.org/blog/2017/02/03/what-is-the-relative-value-of-an-infectious-diseases-physician/">lowest paid</a> physicians in the US<br /><br />Fact 2: Many infectious diseases, <a href="https://academic.oup.com/cid/article/58/5/688/364950/Accuracy-of-Administrative-Code-Data-for-the">including HAI</a>, are absent from ICD billing codes or are poorly coded, and thus the true population health impact of infections, particularly MDROs, is invisible<br /><br />Hypothesis: If we could improve ICD codes for infectious diseases, ID salaries would increase and the field could be saved from extinction<br /><br />Many of us on the blog have <a href="http://haicontroversies.blogspot.com/?q=dumpster+fire">lamented</a>&nbsp;about the current state of ID with a particular focus on low relative salaries compared to other medical subspecialties and concerns about the annual fellowship match. If we focus on academic ID, the folks who supposedly will train the next generation, we also need to worry about <a href="https://aricjournal.biomedcentral.com/articles/10.1186/2047-2994-1-5">low levels of NIH funding</a> for anything other than HIV research; a trend that is slowly improving. (Fact 1, above)<br /><br />Our group has looked at the accuracy of ICD billing codes for both HAI and MRSA and the results are not pretty. Michi Goto <a href="https://academic.oup.com/cid/article/58/5/688/364950/Accuracy-of-Administrative-Code-Data-for-the">completed a systematic review</a> of ICD code accuracy for CDI, SSI, VAP/VAE, CLABSI, CAUTI, post-procedure pneumonia and MRSA. He found that apart from CDI and orthopedic SSI, the codes have poor sensitivity and specificity. Marin Schweizer <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3663328/">looked</a> at the validity of the V09 code pre-2008 for MRSA and found it to be a very poor at detecting proven incident MRSA infection. (Fact 2, above)<br /><br />Since many of those studies were completed, there have been new codes added for CLABSI (October 2011), VAE/VAP (October 2008), MRSA infections (October 2008), and post-procedure pneumonia (October 2012). So there is some hope that HAI and MRSA will become better recognized. But what about MDROs? &nbsp;Investigators from Wash U (including co-blogger Hilary) just published a <a href="https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/icd9cm-coding-for-multidrug-resistant-infection-correlates-poorly-with-microbiologically-confirmed-multidrug-resistant-infection/FF21BAFED6961DCE4D90FB614E2534D5">research letter in ICHE</a> that calculated the sensitivity of ICD-9 codes for various MDRO at their hospital between 2006 and 2015. The gold-standard was a culture at a sterile site or BAL/brochial wash culture with an MDR-Enterobacteriaceae, Enterococcus spp., <i>Staphylococcus aureus</i>, <i>Pseudomonas aeruginosa</i>, or Acinetobacter spp.<br /><br />As you can see in their Table 1, apart from MRSA (after 2008 code added) and&nbsp;<i>P. aeruginosa, </i>ICD organism coding had poor sensitivity and MDRO/V09 codes were - terrible. The authors concluded: "ICD-9-CM diagnosis codes cannot be used to estimate the burden of MDRO infections in hospitals." &nbsp;I think we'd all agree. I would have liked to see more information on the specificity and positive/negative predictive values of individual codes (I understand this was a Research Letter). &nbsp;I'm not sure what the ultimate solution is, but perhaps SHEA or IDSA (or ASM) could work to update ICD-10 codes and come up with ways to encourage accurate coding for infectious diseases. If we don't make sure infections "exist" in administrative data, the field of infectious diseases might not exist for long.<br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://3.bp.blogspot.com/-_7Md-DugE_A/WbwFcsJic_I/AAAAAAAACes/lQgc5KjUk209jII59557vREfOTnwZ4pTwCLcBGAs/s1600/Table%2B1.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="733" data-original-width="1600" height="291" src="https://3.bp.blogspot.com/-_7Md-DugE_A/WbwFcsJic_I/AAAAAAAACes/lQgc5KjUk209jII59557vREfOTnwZ4pTwCLcBGAs/s640/Table%2B1.png" width="640" /></a></div><br />image <a href="https://medicodingsolutions.wordpress.com/2013/12/14/the-transition-from-icd-9-cm-to-icd-10-cm/">source</a>http://haicontroversies.blogspot.com/2017/09/icd-coding-and-mdro-if-you-dont-bill.htmlnoreply@blogger.com (Eli Perencevich)1tag:blogger.com,1999:blog-8066238290370557389.post-2690225811995758028Thu, 14 Sep 2017 16:45:00 +00002017-09-14T11:52:50.730-05:00Nasia SafdaropioidoutbreakSerratiaWisconsinWhen the US opioid epidemic causes a Serratia outbreak<div class="separator" style="clear: both; text-align: center;"><a href="https://2.bp.blogspot.com/-28DEcRpZLtg/WbqahUZWMvI/AAAAAAAACec/PfG7ZyMxybAQNZsI5K0LOfezuvxY0rbxQCLcBGAs/s1600/opioid%2Bepidemic.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="990" data-original-width="1060" height="297" src="https://2.bp.blogspot.com/-28DEcRpZLtg/WbqahUZWMvI/AAAAAAAACec/PfG7ZyMxybAQNZsI5K0LOfezuvxY0rbxQCLcBGAs/s320/opioid%2Bepidemic.png" width="320" /></a></div>We are in the midst of an <a href="http://www.chicagotribune.com/news/opinion/commentary/ct-opioid-crisis-united-states-20170717-story.html">almost</a> unprecedented opioid epidemic in the U.S. &nbsp;Last year (2016), overdoses <a href="https://www.nytimes.com/interactive/2017/09/02/upshot/fentanyl-drug-overdose-deaths.html">caused</a> 64,000 deaths, which was a 22% increase from the previous year, while fentanyl-associated deaths increased by 540% over the past three years. (I wanted to add a thousand exclamation points after the 540, but&nbsp;<a href="http://www.bbc.com/culture/story/20170301-what-overusing-exclamation-marks-says-about-you">thought</a> better of it)<br /><br />Fifteen years ago, Belinda Ostrowsky <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa012370#t=abstract">reported</a> a 26-patient outbreak of <i>S. marcescens </i>bacteremia in a surgical ICU that was ultimately linked to contamination of fentanyl by a respiratory therapist who had diverted the narcotic for their own use. (The CDC has a nice <a href="https://www.cdc.gov/injectionsafety/drugdiversion/index.html">webpage</a> describing 30-years of HAIs associated with drug diversion by healthcare workers)<br /><br />Given the current opioid epidemic, we should expect an increase in hospital outbreaks associated with narcotic diversion. So, it is not surprising to read about a five-patient cluster of <i>S. marcescens</i> bacteremia linked to narcotic diversion by a PACU nurse just <a href="https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/serratia-marcescens-bacteremia-nosocomial-cluster-following-narcotic-diversion/2233B7124CC412E9FF080689AA11E749">described in ICHE</a> by Nasia Safdar and colleagues at University of Wisconsin. Even before the <i>Serratia</i> cluster was identified, a nurse found hydromorphone and morphine PCA syringes with the tamper-evident caps no longer intact and drug levels undetectable in a locked automated medication dispensing cabinet. The subsequent investigation eventually found 42 syringes had been tampered with and narcotics replaced with saline or lactate ringers before the nurse was fired. Unfortunately, even though the outbreak was clonal, the tampered syringes were destroyed before they could be cultured. However, four patients were epi-linked to the PACU nurse and the fifth patient was the nurse's father. (I resisted adding an exclamation point here too)<br /><br />There you have it, but if you want to read beyond the ICHE report, there is an interview of Dr. Safdar over at <a href="https://www.statnews.com/2017/09/14/blood-infection-medical-mystery/">STAT</a>. We certainly don't need more things to worry about with the current opioid epidemic, but we should all make sure we keep talking with our pharmacy colleagues about narcotic thefts and keeping our theft policies and prevention practices up to date.<br /><br />http://haicontroversies.blogspot.com/2017/09/when-us-opioid-epidemic-causes-serratia.htmlnoreply@blogger.com (Eli Perencevich)1tag:blogger.com,1999:blog-8066238290370557389.post-5730416779377178456Mon, 11 Sep 2017 18:45:00 +00002017-09-11T13:53:42.100-05:00DonateearthquakeHarveyHurricaneIrmaRace Against ResistanceSHEASHEA FoundationDonationWhat a terrible couple of weeks. Hurricanes Harvey and Irma, not to mention a huge earthquake in Mexico, pummeled North America. If possible, one of the things that we can do in these situations is donate to recovery efforts. Here are a couple suggestions for places where you can donate:<br /><br />UNICEF has <a href="https://www.unicefusa.org/press/releases/unicef-rapid-assessment-teams-heading-chiapas-and-oaxaca-following-mexico-earthquake">sent teams</a> to Chiapas and Oaxaca and has expanded their fundraising efforts to cover those affected by the hurricanes and earthquakes. <a href="https://www.unicefusa.org/">Donate</a>&nbsp;please<br /><br />The five living past Presidents have started the One America Appeal, which initially responded to Harvey but has been expanded to assist with Florida's recovery. <a href="https://www.oneamericaappeal.org/">Donate</a>&nbsp;please<br /><br />Finally - and we have been hesitant to even mention this - &nbsp;many SHEA members have completed races to raise funds for antimicrobial stewardship scholarships through the <a href="https://www.shea-online.org/index.php/foundation">SHEA Education &amp; Research Foundation's</a> "Race Against Resistance." Runners have included fellow bloggers <a href="https://www.crowdrise.com/race-against-resistance-2017/fundraiser/tomtalbot">Tom</a> and <a href="https://www.crowdrise.com/race-against-resistance-2017/fundraiser/scottfridkin-emory">Scott</a>. Not to be outdone, the&nbsp;<a href="https://www.crowdrise.com/race-against-resistance-2017/fundraiser/teamiowa">University of Iowa has put together a team 5k run</a> on September 30th. &nbsp;We hope you can contribute to this important educational and prevention effort. <a href="https://www.crowdrise.com/race-against-resistance-2017/fundraiser/teamiowa">Donate</a>&nbsp;please<br /><br /><div style="text-align: center;">Thank you</div><div style="text-align: center;"><br /></div><div style="text-align: center;"><a href="http://3.bp.blogspot.com/-zvSO9dC7MSk/WbbYA5_T6QI/AAAAAAAACeI/3Qz9RGDsZIgU4DFge2EWt1MMqLQ2S1XTgCK4BGAYYCw/s1600/Screen%2BShot%2B2017-09-11%2Bat%2B1.37.24%2BPM.png" imageanchor="1"><img border="0" height="337" src="https://3.bp.blogspot.com/-zvSO9dC7MSk/WbbYA5_T6QI/AAAAAAAACeI/3Qz9RGDsZIgU4DFge2EWt1MMqLQ2S1XTgCK4BGAYYCw/s640/Screen%2BShot%2B2017-09-11%2Bat%2B1.37.24%2BPM.png" width="640" /></a></div>http://haicontroversies.blogspot.com/2017/09/donation.htmlnoreply@blogger.com (Eli Perencevich)0tag:blogger.com,1999:blog-8066238290370557389.post-2762835314419724029Tue, 05 Sep 2017 14:22:00 +00002017-09-05T11:58:03.639-05:00CLABSICMSmethodsNHSNsurveillance biasAre "One-Offs" Becoming Routine<div class="separator" style="clear: both; text-align: center;"></div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span><br /><div align="center" class="MsoNormal" style="background: white; margin-bottom: .0001pt; margin-bottom: 0in; mso-line-height-alt: 14.4pt; mso-outline-level: 1; text-align: center; vertical-align: middle;"><span style="color: #3b3e41; font-family: &quot;times new roman&quot; , serif; font-size: 50.5pt; letter-spacing: 0.2pt;">one–off<o:p></o:p></span></div><div align="center" class="MsoNormal" style="background: white; line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: center; vertical-align: middle;"><span style="font-family: &quot;helvetica&quot; , sans-serif; font-size: 13.5pt;"><a href="https://www.merriam-webster.com/dictionary/one-off?pronunciation&amp;lang=en_us&amp;dir=o&amp;file=oneoff01" title="How to pronounce one–off (audio)"><span style="color: #ae0015; letter-spacing: 0.5pt;">play</span></a><o:p></o:p></span></div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"> </span><br /><div align="center" class="MsoNormal" style="background: white; line-height: 15.6pt; margin-bottom: .0001pt; margin-bottom: 0in; text-align: center;"><i><span style="color: #5690b1; font-family: &quot;helvetica&quot; , sans-serif; font-size: 14.0pt; letter-spacing: 0.6pt;"><a href="https://www.merriam-webster.com/dictionary/adjective"><span style="color: blue; letter-spacing: 0.5pt;">adjective</span></a></span></i><span style="color: #5690b1; font-family: &quot;helvetica&quot; , sans-serif; font-size: 14.0pt; letter-spacing: 0.6pt;">&nbsp;\ˌwən-ˈȯf\<o:p></o:p></span></div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">After eight years investigating hospital outbreaks, and about 15 years trying to make the best possible use of surveillance data while at CDC, I still struggle with the tensions inherent in mixing surveillance and performance measurement. The past decade has been a roller-coaster of thrills and perhaps some spills in terms of attention, resources, refinement, and usefulness of HAI surveillance led by CDC; yes, you could probably blame me for several aspects of NHSN reporting you may find unsatisfying (take your pick – perhaps I will expand another day). However, I having recently retired from CDC and am transitioning to Emory Healthcare and Emory University. Although It has been almost eight months. It has been a fascinating transition. The learning curve is steep, and not just for re-entering clinical medicine (that is another story), but also navigating the pathway which integrates the business of healthcare delivery, quality of healthcare delivery, and research opportunities. Slightly easier was learning how to navigate the Emory Parking situation (took 3 months). Much easier was recognizing that the performance quality metrics linked to HAI prevention are getting a lot of attention and a lot of action. It only took a few sessions listening to the quality improvement teams reporting on their target HAIs to understand two things. First, the C suite leaders really care. I had assumed this while at CDC, but it was illuminating to see up close how hard these teams worked to influence HAI prevention. Second, it was becoming somewhat routine to report out on “exceptions to the rules” of HAI reporting. There are many names for those scenarios when an HAI is justifiably reported, but either considered not preventable with evidence based prevention practices or not clinically the infectious event represented by the HAI. While at CDC we routinely heard about these: CLABSIs that “shouldn’t really be counted”, MRSA BSIs that really “weren’t ours”, CAUTIs that really don’t represent an infection. Now these reported HAIs were being called “one-offs.” </span><br /><div class="separator" style="clear: both; text-align: center;"><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"></span></div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"> </span><br /><div class="separator" style="clear: both; text-align: center;"><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><a href="https://1.bp.blogspot.com/-jhFG3504w5A/Wa6u2SIdV2I/AAAAAAAAAA4/p_ibujPDY_M5ONuyt7lyMraut7pagSY7ACLcBGAs/s1600/boxing.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="194" data-original-width="259" height="149" src="https://1.bp.blogspot.com/-jhFG3504w5A/Wa6u2SIdV2I/AAAAAAAAAA4/p_ibujPDY_M5ONuyt7lyMraut7pagSY7ACLcBGAs/s200/boxing.jpg" width="200" /></a></span></div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span></span><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">The </span><a href="http://www.nytimes.com/2010/07/04/magazine/04FOB-onlanguage-t.html" style="font-family: Arial, Helvetica, sans-serif;">NYT</a><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"> reports the term ”one-off” comes from earlier industrial beginnings with the quantity of items produced in manufacturing process, such as taking one-off, two-off, or twelve-off the line to sample or give-away. However nowadays it can refer to any exception of the rule – such as a recent one-off </span><a href="https://www.nytimes.com/2017/08/24/sports/mcgregor-ufc-boxing.html?mcubz=0&amp;_r=0" style="font-family: Arial, Helvetica, sans-serif;">boxing</a><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"> match that really should not ever have happened.&nbsp;</span><br /><div><div class="separator" style="clear: both; text-align: center;"></div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">In an HAI paradigm where we aim for 0 infections, one-offs may either be unavoidable (not preventable) or wrongly attributed to the device, location, procedure. I have historically known of these in terms of byproduct of using proxy measures. I had previously published an <a href="https://www.ncbi.nlm.nih.gov/pubmed/21356430">editorial</a> on the value of proxy measures of infection as a tool for quality improvement (Meaningful measure of performance: A foundation built on valid, reproducible findings from surveillance of health care-associated infections). <br /><br />In that editorial, we outlined necessary steps to reduce the inaccuracies inherent in using such an approach. Now that progress has been made in HAI prevention since 2010/2012, many of these HAI events that conspicuously remain and continue to plague our patients, often don’t fit neatly into the intent of the surveillance definitions. Left with these “one-offs,” it is often difficult to know what to do more to prevent them. Surgical patients with fistulas and central lines that don’t have an infection related to insertion or maintenance processes, neutropenic patients that don’t quite meet the definition of MBI-BSI, I have even heard of tissue transplantation related bacteremia categorized as CLABSI. No doubt, changes have occurred since 2011 to improve CAUTI reporting, and <a href="https://www.ncbi.nlm.nih.gov/pubmed/27856070">neutropenia-related</a> bacteremia. However, the pace is slow. The one-offs are starting to pile up. Perhaps improved risk adjustment of HAI data will mitigate the influence of the one-offs on healthcare facility performance measures. Until then, kudos to the quality folks and infection control teams making prevention progress. However, I hope we can reward them soon with improved performance measures. Perhaps there are surveillance lessons that can be learned from these one-offs after all.&nbsp;</span><br /><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">I<b>f you are interested in sharing one-off stories I have started a registry</b> <a href="https://rsph.co1.qualtrics.com/jfe/form/SV_3wqW5eTNoiVo1qR">here</a> - maybe we can fill in some gaps and accelerate the process of changes in surveillance methods. </span></div>http://haicontroversies.blogspot.com/2017/09/are-one-offs-becoming-routine.htmlnoreply@blogger.com (scott fridkin)4tag:blogger.com,1999:blog-8066238290370557389.post-2531084731418648630Tue, 29 Aug 2017 16:09:00 +00002017-08-29T12:45:48.228-05:00antimicrobial textilesASCOTCDCDukePrevention EpicentersscrubstextilesAnd what about antimicrobial scrubs?<a href="https://4.bp.blogspot.com/-qQUCAbIQ6rg/WaWHUZC8QLI/AAAAAAAACdc/Y-xQo-PaCuEVKHbsAMDRGdeHQk7b5xBcwCLcBGAs/s1600/ascot.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="560" data-original-width="704" height="254" src="https://4.bp.blogspot.com/-qQUCAbIQ6rg/WaWHUZC8QLI/AAAAAAAACdc/Y-xQo-PaCuEVKHbsAMDRGdeHQk7b5xBcwCLcBGAs/s320/ascot.jpg" width="320" /></a><br /><a href="https://en.wikipedia.org/wiki/Ascot_tie">Ascot</a>: a neckband with wide pointed wings, traditionally made of pale grey patterned silk<br /><br />The role that environmental transmission plays in the spread of important pathogens is increasingly recognized. One of the major mechanisms by which pathogens are thought to spread is via contaminated healthcare worker clothing. A major reason that gowns are included in contact precaution is that they are felt to interrupt the transmission from patient/environment to HCW attire. An old (2010) <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3010849/">study</a> that Dan Morgan completed found that gowns became contaminated 11% of the time when caring for patients with MDR-Acinetobacter and 5% of the time when caring for patients with MDR-Pseudomonas. A repeat (2012) <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3534819/">study</a> found that gowns became contaminated during 4% of HCW visits caring of MRSA+ patients, 5% for VRE, 2% for MDR-Pseudomonas and 13% for MDR-Aceintobacter.<br /><br />With so much contamination and a desire to rid the world of unnecessary gown use, investigators have been exploring the benefits of antimicrobial textiles, such as scrubs. If these novel scrubs could reduce contamination, maybe we could drop the dreaded gown and go with universal gloves for contact precautions?<br /><br />Which brings us to a <a href="https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/antimicrobial-scrub-contamination-and-transmission-ascot-trial-a-threearm-blinded-randomized-controlled-trial-with-crossover-design-to-determine-the-efficacy-of-antimicrobialimpregnated-scrubs-in-preventing-healthcare-provider-contamination/CC3DAA1132619E835EC2BABA9F0C7686/core-reader">ASCOT study</a> by Deverick Anderson and colleagues funded by the CDC Prevention Epicenters Program. <i>ASCOT: Antimicrobial Scrub Contamination and Transmission.</i> The investigators examined the benefits of two different antimicrobial scrubs (Scrub 1: silver-alloy and Scrub 2: organosilane-based quaternary ammonium and a hydrophobic fluoroacrylate copolymer emulsion) vs standard poly-cotton surgical scrubs in a 3-arm RCT during 3-consecutive 12-hour ICU nursing shifts. The primary outcome was change in total contamination on the nurses scrubs as sum of CFUs. Of note, all MDRO colonized patients in the study were placed on contact precautions and HCW placed gowns over their scrubs and wore gloves while caring for those patients.<br /><br />The study collected many cultures: 2919 from the environment and 2185 from the HCW clothing. 41 nurses were randomized but one was excluded for a total of 40 nurses caring for 102 patients during 167 encounters. Their primary finding was the scrub type had no effect on HCW clothing contamination (p=0.70) There is a lot to unpack in this study and it warrants a careful read - a lot of data! but I've included Table 3 below with the contamination before/after each shift. Overall, the median CFU increase was 61.5 (interquartile range [IQR], −3.0 to 191.0) in the control arm, 73.0 (IQR, −107.0 to 194.0) in the Scrub 1 arm, and 54.5 (IQR, −60.0 to 215.0) in the Scrub 2 arm.<br /><br /><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-nT3YbCSD_AM/WaWNyJvL5gI/AAAAAAAACds/n-TO6PQIbzgOyb7ib_q05XOyafetIKsuACLcBGAs/s1600/table%2B3.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="317" data-original-width="1600" height="126" src="https://1.bp.blogspot.com/-nT3YbCSD_AM/WaWNyJvL5gI/AAAAAAAACds/n-TO6PQIbzgOyb7ib_q05XOyafetIKsuACLcBGAs/s640/table%2B3.png" width="640" /></a></div><br />There were acquisition events during 39 (33%) of the shifts with 20 (17%) environmental acquisitions and 19 (16%) acquisitions on HCW attire. Looking at the 19 HCW attire acquisition events, 12 (63%) were confirmed: 7 from the patient, 3 from environmental contamination, and 2 from the patient/environment. <br /><br />Overall, the authors reported that there were no benefits from either antimicrobial scrub. However, there was significant transmission from patient or environment to HCW attire. &nbsp;Back to the drawing board on antimicrobial scrubs? &nbsp;Maybe. I would like to see the study repeated in a hospital where contact precautions are not used to see if benefits might exist in settings where gowns are not worn when caring for MDRO+ patients. With this much acquisition of nurses' clothing, it's going to be hard to ditch gowns, unfortunately.<br /><br />Oh, and I love the <a href="https://de.aliexpress.com/w/wholesale-ascot-tie-silk.html">ASCOT</a> name. Brilliant.<br /><br /><br /><br />http://haicontroversies.blogspot.com/2017/08/and-what-about-antimicrobial-scrubs.htmlnoreply@blogger.com (Eli Perencevich)0tag:blogger.com,1999:blog-8066238290370557389.post-6195277060135025159Thu, 24 Aug 2017 03:08:00 +00002017-08-23T22:08:33.363-05:00cartoonDiagnostic StewardshipJCMpositive predictive valueThe cartoon editorial, microbiology edition: An idea whose time has come!<span style="font-family: Arial, Helvetica, sans-serif;">I was excited to read the editorial in this month’s Journal of Clinical Microbiology (JCM), by Alex McAdam (JCM Editor in Chief), entitled “<a href="http://jcm.asm.org/content/55/9/2566.full">Prevalence and Predictive Values</a>”. You can read it here too, because I’ve pasted it below:</span><div><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-QQYygbDrzHA/WZ5CEJ7ozxI/AAAAAAAABeQ/POB9XvDkK0E2K8LlthhLThcg1esLS_aOQCLcBGAs/s1600/F1.large.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="1200" height="640" src="https://1.bp.blogspot.com/-QQYygbDrzHA/WZ5CEJ7ozxI/AAAAAAAABeQ/POB9XvDkK0E2K8LlthhLThcg1esLS_aOQCLcBGAs/s640/F1.large.jpg" width="479" /></a></div><div><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div><div><span style="font-family: Arial, Helvetica, sans-serif;">Brilliant—a simple concept (diagnostics 101!) explained in a simple format. And as an associate editor of JCM, I can attest that this concept is frequently missed by submitting authors, not to mention practicing clinicians and hospital epidemiologists.&nbsp;</span></div><div><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div><div><span style="font-family: Arial, Helvetica, sans-serif;">This issue is also foundational to <a href="http://haicontroversies.blogspot.com/2017/08/diagnostic-stewardship.html">diagnostic stewardship</a>, as it emphasizes the importance of limiting diagnostic testing to patients who have a reasonable pre-test likelihood of disease (pre-test likelihood being the individual-patient equivalent of population prevalence).&nbsp;</span></div><div><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div><div><span style="font-family: Arial, Helvetica, sans-serif;">It also explains why we’ll never “get to zero” for healthcare-associated infections (HAIs), even if all HAIs were preventable. Take the example of hospital-onset <i>C. difficile</i> infection (HO-CDI). The more successful your prevention program is at reducing whatever the “true” incidence of HO-CDI is, the lower will be the population prevalence—and the lower the positive predictive value (PPV) for the very sensitive CDI tests we now use. Positive tests will still occur, no doubt, and will be counted toward the HO-CDI rate—but they’ll be increasingly likely to be clinical false positives.&nbsp;</span></div><div><span style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div><div><span style="font-family: Arial, Helvetica, sans-serif;">Now I need to go start working on a good cartoon editorial about whether CAUTI exists….</span><style><!-- /* Font Definitions */ @font-face {font-family:"ＭＳ 明朝"; panose-1:0 0 0 0 0 0 0 0 0 0; mso-font-charset:128; mso-generic-font-family:roman; mso-font-format:other; mso-font-pitch:fixed; mso-font-signature:1 134676480 16 0 131072 0;} @font-face {font-family:"ＭＳ 明朝"; panose-1:0 0 0 0 0 0 0 0 0 0; mso-font-charset:128; mso-generic-font-family:roman; mso-font-format:other; mso-font-pitch:fixed; mso-font-signature:1 134676480 16 0 131072 0;} @font-face {font-family:Cambria; panose-1:2 4 5 3 5 4 6 3 2 4; mso-font-charset:0; mso-generic-font-family:auto; mso-font-pitch:variable; mso-font-signature:-536870145 1073743103 0 0 415 0;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {mso-style-unhide:no; 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mso-header-margin:.5in; mso-footer-margin:.5in; mso-paper-source:0;} div.WordSection1 {page:WordSection1;} --></style></div></div>http://haicontroversies.blogspot.com/2017/08/the-cartoon-editorial-microbiology.htmlnoreply@blogger.com (Dan Diekema)0tag:blogger.com,1999:blog-8066238290370557389.post-5378315970627193808Thu, 10 Aug 2017 17:49:00 +00002017-08-10T12:49:26.477-05:00Summer Quick Hits (with the Award for the Most Eyebrow-Raising Article Title of the Year)<br /><div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-ZewUaEHcJjg/WYybXio2ULI/AAAAAAAAAEU/JhVcqNOqwS8vE9vIgUZHbe2AMbUiGaCqACLcBGAs/s1600/Count.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="350" data-original-width="305" height="320" src="https://1.bp.blogspot.com/-ZewUaEHcJjg/WYybXio2ULI/AAAAAAAAAEU/JhVcqNOqwS8vE9vIgUZHbe2AMbUiGaCqACLcBGAs/s320/Count.jpg" width="278" /></a></div><br /><br />Trying to recover from summer vacation (Alaska = thumbs up, especially during a summer heat wave) and gear up for a new school (and blogging)&nbsp;year, so here are a few quick hits from recent articles:<br /><br />Two articles highlight several HAIs that aren't often included in surveillance and prevention efforts:<br /><br /><ul><li>Len Mermel has a nice <a href="https://academic.oup.com/cid/article/doi/10.1093/cid/cix562/4079720/Shortterm-Peripheral-Venous-CatheterRelated">systematic review</a> in <em>CID</em> examining the burden of bloodstream infection related to short-term peripheral venous catheters (a.k.a. peripheral IVs - not midline or PICCs).&nbsp; Used in a substantial number of hospitalized patients (esp. as we're better&nbsp;about central line necessity), these devices have a much lower risk of BSI when compared to central venous catheters (2-64 fold higher risk for CVCs); however, given the vast number of devices used (Len estimates ~200 million adult patients in the U.S. annually), the number of BSI events&nbsp;are likely high.&nbsp;A number of interesting details are in the paper, so worth checking out.&nbsp;</li><li>A nice <a href="http://www.thelancet.com/journals/lanres/article/PIIS2213-2600(17)30296-5/fulltext">commentary</a> out of the UK in <em>Lancet Respiratory Medicine</em> advocates for an increased focus on healthcare-associated pneumonia, particularly that which occurs outside of the ICU (and is not ventilator-associated).&nbsp; </li></ul>Both of these papers highlight HAIs that are not in the "Big 5" (CLABSI, CAUTI, SSI, MDROs/<em>C. diff</em>, and VAE) but cause patient harm.&nbsp; Broadening an IP surveillance and prevention program to include these events does have some challenges, however.&nbsp; The worry about objective surveillance definitions that came to a head with VAP certainly applies to HAP, and the volume of patients at risk for a PIV-related BSI invites the need for an automated system for surveillance.&nbsp; Nonetheless,&nbsp;with reductions in the Big 5 (well, except VAE as I'm still not sure how to tackle that one), it's perhaps time we look to expand our scope.<br /><br />Finally, a paper that wins the award for the most eyebrow-raising title of the year: "<a href="https://academic.oup.com/cid/article/doi/10.1093/cid/cix697/4077089/Hematophagous-Ectoparasites-of-Cliff-Swallows">Hematophagous Ectoparasites of Cliff Swallows Invade a Hospital and Feed on Humans</a>."&nbsp; Try reading that without&nbsp;saying "What?? Gross."&nbsp; The authors outline their&nbsp;nosocomial "outbreak" of two ectoparasites related to a massive swallow roost on the outside of a community hospital.&nbsp; One inpatient noted a rash illness, and testing of ticks and bugs identified the presence of human blood in 17% of the captured critters.&nbsp; Hospital invasion!&nbsp; Feeding on humans!&nbsp;Talk about a riveting agenda for your next&nbsp;infection prevention committee meeting!http://haicontroversies.blogspot.com/2017/08/summer-quick-hits-with-award-for-most.htmlnoreply@blogger.com (Tom Talbot)0tag:blogger.com,1999:blog-8066238290370557389.post-8105935784750195533Fri, 04 Aug 2017 19:36:00 +00002017-08-04T14:49:44.635-05:00Diagnostic StewardshipjamaDiagnostic Stewardship<div class="separator" style="clear: both; text-align: center;"><a href="https://1.bp.blogspot.com/-Xw0lcKDxlGw/WYTJ5h7fPzI/AAAAAAAABdg/O89009T1GDMLJRpKaGa-h71HRx_UDNHeACLcBGAs/s1600/Headshot%2Bcasual%2BLown.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="466" data-original-width="374" height="200" src="https://1.bp.blogspot.com/-Xw0lcKDxlGw/WYTJ5h7fPzI/AAAAAAAABdg/O89009T1GDMLJRpKaGa-h71HRx_UDNHeACLcBGAs/s200/Headshot%2Bcasual%2BLown.jpg" width="160" /></a></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><i>The following is a guest post from Dr. Dan Morgan, GFOTB (Good Friend Of The Blog):</i></span></div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"></span><br /><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span></span></div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">This week Preeti Malani, Dan Diekema and I wrote a <a href="http://jamanetwork.com/journals/jama/article-abstract/2647071">viewpoint in JAMA discussing diagnostic stewardship</a>, or “modifying the process of ordering, performing, and reporting diagnostic tests to improve the treatment of infections and other conditions.” In other words, guiding laboratory ordering to prevent contradictory results and reporting results in a fashion that makes treatment more appropriate. There really are two Criteria for Diagnostic Stewardship modifying laboratory testing:</span><br /><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">1) Does it modify the process of ordering, performing and reporting tests?&nbsp;</span><br /><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">2) Does it improve the appropriateness of patient management?&nbsp;</span><br /><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">When I discussed diagnostic stewardship with my non-medical wife, she asked “you mean they don’t do that? Why would they do tests that contradict other results or provide second or third line antibiotic choices?”&nbsp;</span><br /><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">This is why I think diagnostic stewardship has so much potential. It is about making laboratory ordering more rational, which is hard to debate. Although medicine has existed with the idea that doctors knew best how to order and interpret results, we are now seeing they often don’t, as predicted by psychologists Danny Kahneman and Amos Tversky in the 1970s; “Intuitive judgments are liable to similar fallacies in more intricate and less transparent problems.”&nbsp;</span><br /><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">Doctors ordering and interpreting test results are like other people, often irrational. Diagnostic stewardship makes testing more logical to improve patient care. Ultimately this process shouldn’t be limited to urine cultures, blood cultures and <i>C. difficile</i> testing but applied to new molecular detection panels and non-ID tests, like cascading tests for anemia or limiting PSA testing in young and elderly men. And there has been interest in this idea from <a href="http://www.improvediagnosis.org/">areas outside of ID</a>.&nbsp;</span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;">The fact that diagnostic stewardship reduces false-positive tests that contribute to publicly reported HAIs means there is likely a lot of incentive to support these processes. But we shouldn’t forget there are important patient benefits too, including avoiding unnecessary antibiotics, avoiding the distraction of misdiagnosis, and improving the ability of HAI rates to truly measure care. </span></div></div></div></div></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://3.bp.blogspot.com/-UECiChNMs2M/WYTKAbMnR9I/AAAAAAAABdk/5tgeDYy13UUZdlm1diTc0FRTqLmvzqo2gCLcBGAs/s1600/Diagnostic%2BStewardship%2BTable.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="958" data-original-width="1432" height="427" src="https://3.bp.blogspot.com/-UECiChNMs2M/WYTKAbMnR9I/AAAAAAAABdk/5tgeDYy13UUZdlm1diTc0FRTqLmvzqo2gCLcBGAs/s640/Diagnostic%2BStewardship%2BTable.jpg" width="640" /></a></div><div><span style="font-family: &quot;arial&quot; , &quot;helvetica&quot; , sans-serif;"><br /></span></div>http://haicontroversies.blogspot.com/2017/08/diagnostic-stewardship.htmlnoreply@blogger.com (Dan Diekema)0